*^. 


'     'J 


'     I 


Mi 


-M 


m 


t 

1,^ 

,JI 

<A 

•? 

; 

>      .V 

'■;^ 

1 

'■ir 

i«    -" 

-  r^ 

ife 

^gH 

r^' 

'''^f>^ 

y^i."'  ''^' 


■  V  ■ 


■i^'">.V7"' •^.■f^_ 


^1 


1  .£/  ^  -f 


/ 


/Vw.< 


0 


/^// 


^4, 


ON 


THE  WASTING  DISEASES 


INFANTS  AND  CHILDREN. 


BY 

EUSTACE  SMITH,  M.  D.  Lo^d. 

MEMBER  OF  THE  ROYAL   COLLEGE   OP  PHYSICIANS; 

PHYSICIAN   TO    HIS    MAJESTY   THE   KINtt   OP   THE    BELGIANS; 

PHYSICIAN   TO   THE   NORTHWEST   LONDON   PREE    DISPENSARY    FOR   SICK   CHILDREN; 

AND  TO  THE  METROPOLITAN  DISPENSARY. 


SECOND    AMERICAN, 

FROM  THE 

SECOND  REVISED  AND  ENLARGED  ENGLISH  EDITION. 


PHILADELPHIA: 

nEI>^"EY     C.     LEA 

1871. 


PHILADELPHIA  : 
COLLINS,  PKINTEK,  705  JAYNE  STREET. 


10  0 


TO 

SIR  WILLIAM  JENNER,  Bart.,  M.D.,  D.C.L.,  F.R.S. 

£ljxs  J^'olttmc  is  |n6cribtb 

AVITH    RESPECT    AND    GRATITUDE 
BY  THE  AUTHOR. 


ADVERTISEMENT  TO  THE  SECOND  EDITION. 


In  preparing  a  Second  Edition  of  this  Work  for  the  Press,  the 
text  of  the  First  Edition  has  been  carefully  revised,  inaccuracies 
have  been  corrected,  and  additions  suggested  by  increased  ex- 
perience have  been  freely  introduced. 

Two  new  Chapters  have  been  added.  In  one  (Chapter  VI.) 
will  be  found  the  description  of  a  disease,  very  comraoa 
amongst  children,  which  in  severe  cases  causes  great  disturb- 
ance and  emaciation,  and  is  often  mistaken  for  tuberculosis. 
The  other  (Chapter  XI.)  contains  special  directions  upon  the 
feeding  of  children,  and  presents  a  series  of  carefully-arranged 
dietaries  suitable  to  infants  and  children  of  various  ages,  both 
in  health  and  disease. 

A  few  illustrative  cases  have  been  added  where  illustration 
seemed  advisable,  but  the  Author  has  avoided  overburdening 
the  text  with  the  narration  of  cases,  as  he  was  unwilling 
needlessly  to  increase  the  size  of  the  volume. 


George  Street,  Hanover  Square. 
September  30,  1870. 


PREFACE  TO  THE  FIRST  EDITIOK 


The  extensive  use  of  such  terms  as  "marasmus,"  "tabes," 
"atrophy,"  as  denoting  vaguely  some  slow  disease  fatal  to 
children,  affords  a  strong  presumption  that  diseases  of  which 
wasting  is  a  prominent  symptom  are  but  little  understood, 
and  that  much  loss  of  life  is  due  to  insufficient  knowledge 
of    their   nature. 

The  Author  had  not  long  begun  the  study  of  children's 
diseases  before  he  found  that  even  the  best  systematic  treatises 
dealt  but  imperfectly  with  the  clinical  condition  of  chronic 
wasting,  and  did  not  consider  together — in  the  way  required 
for  every-day  use  in  practice — the  various  disorders  to  which 
it  may  be  due. 

He  was,  accordingly,  induced  to  devote  considerable  attention 
to  this  subject,  with  the  view  of  forming  some  practical  classifi- 
cation, by  means  of  which  the  diseases  giving  rise  to  this  slow 
wasting  might  be  more  readily  recognized  and  controlled. 

As  a  result  of  the  experience  thus  acquired,  he  offers  the 
present  volume  as  a  contribution  to  the  literature  of  the  diseases 
of  children,  in  the  hope  that  it  may  be  found  of  practical  value 
in  the  treatment  of  this  exceedingly  common  and  fatal  condition. 

In  the  chapter  on  pulmonary  phthisis  the  Author  has  endea- 
vored to  utilize  recent  views  on  the  nature  of  the  phthisical 
process ;  but  as  his  aim  has  been  primarily  to  make  his  little  book 
clinically  useful,  he  has  limited  himself  to  matters  of  direct 
practical  significance,  and  has  indulged  little  in  considerations 
of  a  purely  speculative  kind. 


George  Street,  Hanover  Square. 
September,  1868. 


CONTENTS. 


INTRODUCTION. 

Wasting  a  sign  of  defective  nutrition 

Importance  of  detecting  the  cause  of  malnutrition 

Wasting  not  always  the  first  sign,  and  may  even  be  absent  in  slight 

cases     ...... 

Defective  nutrition  may  be  the  result  of  acute  disease 

Liability  of  badly-nourished  children  to  secondary  acute  diseases 

Peculiarities  of  these  secondary  diseases  . 

Insensibility  of  the  nervous  system  in  cachectic  children 

Infrequency  of  reflex  convulsions  . 

Importance  of  diagnosing  the  secondary  diseases 

Information  to  be  derived  from  examining  the  face  of  the  infant 

M.  Jadelot's  traits  ..... 

Color  of  face  ..... 

Breathing     ....... 

Cry  ....... 

Causes  of  large  belly  in  infants 

Infrequency  of  mesenteric  disease  . 

Mode  of  examining  liver  and  spleen 

General  treatment  of  wasting 

Uselessness  of  tonics  so  long  as  there  remains  any  derangement  of  the 

stomach  and  bowels     .... 

Importance  of  minuteness  in  giving  directions  about  diet 
External  applications  .... 

Frictions       ...... 

Anointing  with  warm  olive  oil         . 
Counter-irritants      ..... 

Baths — Hot  bath     ..... 

Mustard  bath  .  .  .  . 

Cold  bath    ..... 

Internal  remedies     ..... 

Cod-liver  oil  must  not  be  given  in  too  large  doses 
Stimulants    i  .  .  .  .  .' 


PAGE 

17 
18 

18 
18 
19 
19 
20 
20 
20 
20 
21 
21 
22 
22 
22 
23 
23 
24 

24 
24 
24 
24 
25 
26 
26 
26 
27 
27 
28 
28 


CHAPTER  I. 

Simple  Atrophy  from  insufficient  Nourishment. 
Causes  ...... 

Insufficient  supply  of  food 

Yaiieties  of  breast  milk   . 

Effect  of  preponderance  of  butter  in  milk 

Test  of  a  good  nurse 


29 
29 
30 
30 
30 


Vlll 


CONTENTS, 


Unsuitable  food 

Dependence  of  nutrition  upon  powers  of  digestion 
Over-feeding  .... 

Varieties  of  food  required  for  perfect  nutrition 
Differences  between  woman's  and  cow's  milk 
Cow's  milk  cannot  always  be  digested 
Symptoms    .... 
Two  classes  according  to  cause 
Food  suitable,  but  insufficient 
Food  unsuitable     . 
Wasting 
Constipation  . 

Cause  of  inactivity  of  bowels 
Flatulence 
Colic  . 

Ravenous  appetite    . 
Eruptions  on  skin 

Strophulus 
Urticaria  . 
Thrush,  its  importance  in  prognosis 
Inward  fits     . 

Attacks  of  vomiting  and  diarrhoea 
Convulsions    . 
Aphthie 

Danger  of  secondary  diseases 
Mode  of  death 
Treatment    .... 
Suckling,  by  mother     . 

by  nurse 
Rules  for  choosing  nurse 
Directions  for  efficient  suckling 
Advantages  of  putting  child  early  to  breast  after  birth 
Time?  of  suckling 
Artificial  feeding 
Directions 
Feeding  bottle  . 

Importance  of  cleanliness  of  bottle 
Farinaceous  foods 
Their  relative  value 
Boiled  flour 

Quantity  of  farinaceous  food  . 
Cow's  milk  may  disagree 
Isinglass 

Liebig's  food  for  infants 
Weaning 

Usual  time 

Must  sometimes  be  anticipated 
Method  of  weaning 
Reasons  why  a  child  may  refuse  breast 
Diet  after  weaning 
General  management  of  infants 
Treatment  of  constipation 

Flatulence  and  acidity 
Convulsions  and  colic 
Thrush     . 
Aphtha?  . 
Diarrhffia  and  vomitinjr 


CONTENTS. 


IX 


CHAPTER    II. 


Chronic  Diarrh(ea. 

May  be  secondary  to  acute  disease 
Or  may  be  primary 

Mode  of  commencement  when  primary 
Increased  peristaltic  action  of  bowels 
When  disease  established 
Character  of  the  stools 
Other  symptoms 
Complications  .... 

Serous  effusions     . 
Pneumonia 
Exanthemata 
Convulsions  rarely  except  towards  commencement 
Thrombosis  of  cerebral  sinuses    . 
Death  without  complication     . 
Diarrhoea  may  cease  before  death 
Influence  of  the  disease  upon  dentition 
Causes — In  infants,  bad  hygiene     . 
Cold 

Previous  acute  disease   . 
In  older  children,  worms  . 

Tubercular  ulcerations  of  bowels 
Anatomical  characters 

Simple  ulceration  of  mucous  membrane 
Tubercular  ulceration  . 
Diagnosis     ..... 
Prognosis — Unfavorable  signs 

Favorable  signs 
Prevention  . 

Attention  to  diet 
Avoidance  of  cold 
Influence   of  dentition 
Treatment    . 

General  management 

Diet 

External  applications 

Internal  remedies 

Antacids 

Astringents 

Enemata 

Opium   . 

Nitrate  of  silver 

Raw  meat  plan 

Tonics  . 


CHAPTER    I  II. 

Chronic  Vomiting. 

Frequency  of  slight  attacks  of  gastric  disturbance 

Such  attacks  easily  remedied 

Chronic  vomiting  non-febrile 
Symptoms    . 

Character  of  vomited  matters 

Constipation 

Interference  with  nutrition 


CONTENTS. 


After  a  time  vomiting  almost  constant 

Exhaustion 

Spurious  hydrocephalus 
Causes 
Diagnosis    . 

From  tubercular  meningitis 

Of  spurious  hydrocephalus 
Treatment    . 

Attention  to  diet 

Eeturn  to  breast 

Substitute  for  wet  nurse 

Warmth 

External  applications 

Baths    . 

Medicines 

Bismuth  and  magnesia 

Calomel 

Dilute  hydrocyanic  acid 

Enemata 

Vinum  ipecacuanhas     . 

Illustrative  case 

Liquor  arsenicalis 

Emetics 

Stimulants 


CHAPTER    IV. 

Rickets. 

Preliminary  symptoms  those  of  general  malnutrition 
Symptoms  of  commencement 
Deformities  of  bone 
Enlargement  of  ends  of  bone 
Softening- 
Thickening  of  flat  bones 
Mechanical  deformities 
Bones  of  skull  and  face 
Distinction  between  rickety  and  hydrocephalic  skull 
Cranio  tabes  . 
Dentition 

Teeth  sometimes  unaffected     . 
Illustrative  case 
Spine     .... 
Thorax 

Deformities  of  long  bones  and  of  pelv 
Arrest  of  growth  of  bones 
Articulations    . 
Relaxation  of  ligaments 
Other  symptoms; 
Enlargement  of  liver  and  spleen 
Intellect 

General  behavior  of  a  rickety  child 
Complications 

Catarrh  and  bronchitis     . 

Diarrhoea  . 

Laryngismus  stridulus 

Convulsions 

Chronic  hydrocephalus     . 
Death  from  intensity  of  the  general  disease 


CONTENTS. 

xi 

PAGE 

Pathology .113 

Eickets  a  general  disease 

113 

Anatomical  characters  of  bone  changes 

114 

Kolliker's  views            .... 

115 

Virchow's  views            .... 

115 

Keconsolidation  of  rickety  bone 

116 

Analysis  of  rickety  bone 

117 

Ephysema  and  collapse 

118 

Alterations  iu  lymphatic  glands 

119 

in  liver      .... 

119 

in  spleen  .... 

119 

in  other  organs    . 

120 

Urine    ...... 

120 

Diagnosis    ...... 

120 

Prognosis    ...... 

122 

Importance  of  complications  . 

122 

Causes          .             .            .            ... 

123 

Rickets  not  a  diathetic  disease 

125 

Bad  feeding  and  hygiene 

125 

Connection  between  rickets  and  syphilis 

126 

Prevention  ...... 

126 

Treatment    ...... 

127 

Diet      ..... 

127 

Attention  to  digestive  organs 

127 

Dry  bracing  air            .             .            . 

128 

Tonics               .... 

129 

Yalue  of  mechanical  supports 

1.30 

Treatment  of  complications     . 

130 

Catarrh      .... 

130 

Diarrhoea  .... 

131 

Convulsions 

132 

Laryngismus  stridulus 

132 

CHAPTER   y. 

Inherited  Syphilis. 

Appearance  of  first  symptoms 

.      133 

Before  birth 

133 

At  birth     .... 

133 

After  birth 

.       134 

Fretfulness  at  night     . 

134 

Snuffling            .... 

.       135 

Necrosis  of  nasal  bones 

135 

Eruptions           .... 

135 

Seat       ..... 

136 

Yarieties           .... 

136 

Ecthymatous  pustules 

136 

Mucous  patches 

137 

Cracks  and  fissures      .            .             . 

137 

Complexion       .... 

.       137 

Cry 

.       138 

Openness  of  fontanelle 

138 

Influence  of  the  disease  on  general  nutrition 

.       138 

Affections  of  internal  organs   . 

.       139 

Liver          .... 

139 

Local  peritonitis   . 

140 

Spleen 

140 

Delayed  symptoms 

.       140 

XI 1 


CONTENTS. 


Syphilitic  teeth 

Relapses  .... 

Diagnosis     ..... 

By  general  symptoms  . 

By  history         .... 

By  examination  of  other  children  of  the  same 

Signs  of  past  disease  in  child  . 
Causes  ..... 

Transmission  of  taint  from  father 

Transmission  of  taint  from  mother 

Mother  seldom  escapes  if  father  affected 

Colles'  law         .... 

Twins  not  always  equally  affected 

Other  modes  of  infection 
Prognosis    ..... 

From  observation  of  parents    . 

From  observation  of  child 

Importance  of  considering  the  intensity  of  th 

Importance  of  certain  special  symptoms 
Prevention   ..... 
Treatment    ..... 

Two  objects      .... 

Treatment  to  be  begun  early   . 

Remarks  on  the  non-mercurial  treatment 

Treatment  by  mercury 

Different  preparations 
External  applications 
Ointment   .... 
Mercurial  baths 

To  improve  general  nutrition  . 

Diet       ..... 

Peculiarities  of  milk  in  syphilitic  mothers 

Other  foods       .... 

Cod-liver  oil      . 

Warmth  .... 

Cleanliness        .... 

Treatment  of  vomiting  and  diarrhoea 

Local  applications 

Tonics  ..... 


e  gener 


family 


al  cache: 


CHAPTER    VI. 


Mucous  Disease. 

Character  of  the  derangement 
Symptoms 

Nightmare 

Somnambulism 

Incontinence  of  urine 

Appearance  of  tongue 

Bowels 

Fetor  of  breath 

Complexion 

Dry  rough  skin 

Temperature 

Bilious  attacks 

Worms  a  common  complication 


CONTEXTS. 

XUl 

PAGE 

Causes          .........       159 

Influence  of  previous  diseases 

160 

Whoopino-cough 

160 

Second  dentition 

.      161 

Diagnosis    . 

161 

From  chronic  tuberculosis 

161 

Value  of  thermometer 

.       162 

Treatvient    . 

.       162 

Diet      . 

.       162 

Exclusion  of  starchy  food 

162 

A  dietary 

163 

Allowable  vegetables  . 

163 

Alcohol 

163 

Restore  action  of  skin 

164 

Warm  clothing 

164 

Internal  remedies 

.       164 

Alkalies 

164 

Aloes    . 

165 

Iron 

165 

Purgatives 

166 

Case  illustrating  treatment 

166 

Acids    .... 

167 

Alum     . 

167 

Cod-liver  oil 

.       168 

Change  of  air  . 

168 

CHAPTER     VII. 

Worms. 

Varieties      ...... 

Description ...... 

Oxyuris  verraicularis    .... 

Ascaris  lumbricoides    .... 

Tricocephalus  dispar    .... 

Taenia  solium    ..... 

Taenia  medio-canellata .... 

Bothriocephalus  latus  .... 

Development  and  mode  of  obtaining  admission  into  human 
Symptoms    ...... 

Due  principally  to   accompanying  derangement  of 
bowels  ..... 

Emaciation       ..... 

Pain      ...... 

Disturbance  of  nervous  system 

Convulsions       ..... 

Symptoms  when  digestive  derangement  is  trifling 

Migration  of  worms      .... 

Special  symptoms  with  each  variety  of  worm 
Diagnosis     ...... 

From  tuberculosis         .... 

From  tubei'cular  meningitis     . 
Treatment    ...... 

Two  objects      .  . 

To  expel  worms    .... 
Eemedies  required  for  each  variety 
Threadworms 
Long  worms  .  . 


, 

.      169 

169 

,                    , 

.       169 

,       170 

.       170 

,                    ^ 

171 

171 

171 

human  body 

172 

174 

f   stomach  and 

174 

^             ^ 

174 

.       174 

, 

175 

^ 

.       175 

175 

, 

176 

^ 

176 

177 

, 

178 

^             ^ 

178 

, 

179 

,             , 

179 

,             ^ 

179 

^             ^ 

179 

,             , 

179 

180 

XIV 


CONTENTS. 


Large  threadworms   .... 

Tapeworms  ..... 
To  restore  healthy  condition  of  alimentary  canal 
Treatment  of  prolapsus  ani 


PAGE 

180 
181 
182 
182 


CHAPTER    VIII. 

Chronic  Tuberculosis. 

A  diathetic  disease  attacking  the  organs  generally 
May  be  acute  or  chronic 

Yellow  infiltrated  tubercle  of  Laennec  not  true  tube 
Two  forms  of  tubercle 

Gray  granulations 

Yellow  granulations 

May  coexist  in  the  same  organ 

Differences  between  them 
Changes  in  tubercle     . 
The  tuberculous  and  scrofulous  types 

Distinct  but  not  antagonistic 
Symptoms     . 

Shape  of  chest . 
Fever     . 
Wasting 
Temperature 
Diagnosis    . 
In  infants 

Value  of  the  thermomete 
In  older  children 
Causes 

The  result  of  a  constitutional  tendency 
Exciting  causes 
Inoculation  of  tubercle 
Prevention   . 
Treatment    . 
Climate 
Exercise 
Fresh  air 
Diet 

Attention  to  digestive  organs 
Astringents 
Alkalies 
Cod-liver  oil 
Tonics  . 


cle 


CHAPTER  IX. 

Chronic  Pulmonary  Phthisis. 

Comprehends  several  distinct  pathological  processes 

Infrequency  of  extensive  pulmonary  disintegration  in  young  children 
Symptoms     . 

Cough   . 

Sputa  usually  swallowed 

Haemoptysis  rare 

Rapidity  of  breathing  . 

Chest  pains 

Diarrhoea 


CONTENTS. 


XV 


Physical  signs         ..... 

Percussion        ..... 
Its  value    .  .  .  . 

Auscultation     ..... 

Importance  of  using  stethoscope 

Yalue  of  stethoscopic  signs 

Bronchial  breathing     .... 

Its  value  as  evidence  of  pulmonary  consolidation  and 
tion     ..... 

Disseminated  miliary  tubercles 

Physical  signs       .... 
Anatomical  characters        .... 

Gray  and  yellow  granulations  . 

Pneumonic  consolidation 

May  remain  unabsorbed  and  become  cheesy 

Softening  and  excavation 

Cavities  ..... 

Cicatrization  of  cavities 

Fibroid  phthisis  .... 

Diagnosis     ...... 

Of  tubercle       ..... 

Of  scrofulous  pneumonia 

Its  complication  with  gray  tubercle     . 
•   Of  fibroid  phthisis        .... 

Of  cavities        ..... 
From  dilated  bronchi 
From  effusion  into  pleura 

Fragments  of  elastic  tissue  in  sputum  as  evidence  of  ulceration 
Prognosis     ...... 

Causes  ...... 

Of  scrofulous  pneumonia 
Treatment    ...... 

General  ..... 

Exercise  ..... 

Fresh  air  ....  . 

Cleanliness        ..... 

Cold  baths  bad  .... 

Climate  ..... 

Attention  to  digestive  organs 
Special         ...... 

Use  of  expectorants     .... 

Use  of  opium    ..... 

Method  of  prescribing  expectorants    . 

Alkalies  ...... 

Treatment  of  unabsorbed  pneumonic  deposits 

Counter-irritation.         .... 


of  lung 


CHAPTER    X. 


Tuberculization  of  Glands. 

Of  glands  in  general     .  .  .  . 

Of  Bronchial  Glands,  or  Bronchial  Phthisis  . 
Symptoms     ...... 

Produced  by  pressure  on  neighboring  organs 

Pressure  on  veins         .  .  .  . 

Pressure  on  nerves       ,  .  .  . 


XVI 


CONTENTS. 


PAGE 

Physical  signs         ........       229 

Alterations  in  respiratory  sounds  produced  by  pressure  on  trachea 

and  bronchi           .......       229 

Mode  of  termination    .... 

230 

Diagnosis     ...... 

230 

Of   Mesenteric    Glands,   or    Mesenteric   Phthisis    i 

Tabes 

Mesen 

terica             ...... 

231 

Symptoms     ...... 

231 

General             ...... 

231 

Local    ...... 

231 

Pressure  on  veins          .... 

.       232 

Ascites  usually  the  result  of  peritonitis 

232 

Perforation  of  bowel    .... 

.       233 

Diagnosis    ...... 

233 

Only  to  be  made  by  feeling  the  glands 

233 

From  fecal  accumulation 

.       233 

From  tubercle  of  omentum 

.       233 

Anatomical  characters        .... 

.       23.5 

Of  tubercular  glands  in  general 

.       235 

Of  bronchial  glands     .... 

.       235 

Of  mesenteric  glands   .            . 

.       236 

Treatment    ...... 

.       236 

General              .            ,                        .            . 

.       236 

Special  ...... 

.       236 

Of  bronchial  phthisis 

.       236 

Of  mesenteric  phthisis 

.       236 

CHAPTEK    XI, 

Diet  of  Children  in  Health  and  Disease 
Diet  in  health  .... 

From  birth  to  six  months  old  . 

From  six  to  twelve  months  old 

From  twelve  to  eighteen  months  old  . 

From  eighteen  months  to  two  years  old 

After  two  years 
Diet  in  disease 

In  simple  atrophy 

In  chronic  diarrhoea 

In  chronic  vomiting 

In  rickets 

In  mucous  disease 

In  tuberculosis  and  pulmonary  phthisis 


238 
238 
240 
242 
244 
245 
245 
245 
246 
248 
248 
249 
250 


ON 


THE  WASTING  DISEASES 


INFANTS  AND  CHILDREN. 


INTRODUCTION. 

Wasting  a  sign  of  defective  uutrition — Importance  of  detecting  the  cause  of  mal- 
nutrition— Wasting  not  always  the  first  sign,  and  may  even  be  absent  in 
slight  cases — Defective  nutrition  may  be  the  result  of  acute  disease— Liability 
of  badly-nourished  children  to  secondary  acute  diseases — Peculiarities  of 
these  secondary  diseases — Insensibility  of  the  nervous  system  in  cachectic 
children — Infrequency  of  reflex  convulsions — Importance  of  diagnosing  the 
secondary  diseases — Information  to  be  derived  from  examining  the  face  of  the 
infant — M.  Jadelot's  "  traits'' — Color  of  face — Breathing — Cry — Causes  of  the 
large  belly  in  infants — Infrequency  of  mesenteric  disease — Mode  of  examining 
liver  and  spleen. 

General  Treatment  of  Wasting — Uselessness  of  tonics  so  long  as  there  remains  any 
derangement  of  the  stomach  or  bowels — Importance  of  minuteness  in  giving 
directions  about  diet.  External  Applications. — Frictions — Counter-irritants — 
Baths — Hot — Mustard — Cold.  Internal  Remedies. — Cod-liver  oil  must  not  be 
given  in  too  large  doses — Stimulants. 

Wasting  is  a  sign  of  defective  nutrition :  tbe  waste  of  the  body 
continues,  but  new  material  is  introduced  in  quantity  insufficient  to 
supply  the  loss  of  tissue. 

Wasting  may  be  temporary  or  persistent.  Every  deviation 
from  health  will  affect  to  a  certain  extent  the  nutrition  of  the  body, 
and  according  as  the  interference  with  nutrition  is '  more  or  less 
complete,  the  wasting  goes  on  with  more  or  less  rapidity.  The 
interference  is  great  in  proportion  to  the  acuteness  of  the  cause 
which  produces  it.  Any  acute  disorder,  such  as  an  inflammatory 
attack  or  an  attack  of  acute  diarrhoea,  will  produce  an  immediate 
pause  in  the  nutritive  process :  the  flesh  at  once  begins  to  feel 
flabby  and  soft,  and  a  continuance  of  the  purging,  if  the  drain  be 
2 


18  INTRODUCTION. 

severe,  causes  a  visible  loss  of  flesh,  which  is  as  rapid  as  it  is 
alarming.  On  the  cessation  of  the  acute  attack,  the  flesh  is  re- 
covered almost  as  rapidly  as  it  was  lost:  a  few  days  restore  the 
child's  ordinary  appearance,  and  with  his  flesh  his  color  and  spirits 
return.  On  the  other  hand,  in  chronic  disorders,  emaciation  pro- 
ceeds much  more  gradually,  but  nutrition,  as  it  is  slowly  impaired, 
is  also  slow  to  be  re-established.  The  present  volume  deals  only 
with  cases  of  slow  impairment  of  nutrition,  where  the  loss  of  flesh 
is  gradual,  and  the  wasting  cannot  be  attributed,  at  any  rate  directly, 
to  any  acute  febrile  attack.  In  all  such  cases  the  cause  should  be 
carefully  inquired  for,  as  the  defect  in  nutrition  can  only  be  effect- 
ually remedied  by  removing  the  cause  which  has  produced  it. 
This  cause  may  be  unsuitable  food,  the  child  being  actually  starv- 
ing from  his  inability  to  digest  and  assimilate  the  diet  with  which 
he  is  supplied.  He  may  be  prevented  from  assimilating  an  ordi- 
narily digestible  diet  by  some  unhealthy  condition  of  his  alimentary 
canal ;  or  some  constitutional  defect,  as  the  existence  of  tuberculosis, 
or  the  poison  of  syphilis  pervading  the  system,  may  interfere  with 
the  proper  nutrition  of  the  tissues. 

It  is  extremely  important  to  detect  the  earliest  symptoms  of 
defective  nutrition.  Wasting  is  not  always  one  of  the  first  signs, 
and  may  even  be  altogether  absent  if  the  interference  with  nutrition 
is  not  carried  to  a  high  degree.  Thus,  a  child  may  be  exceedingly 
plump,  and  even  excite  admiration  by  his  good  condition,  although 
he  may  at  the  same  time  be  suffering  from  the  insidious  com- 
mencement of  rickets,  which,  if  the  causes  producing  the  disease 
continue  unchecked^  will  shortly  assert  itself  unmistakably.  Acute 
disease  is  frequently  a  starting-point  for  mal-nutrition,  either  by 
awakening  a  dormant  diathetic  tendency,  or  by  leaving  behind  it 
a  chronic  derangement  of  the  alimentary  canal,  or  by  impeding 
nutrition  by  some  mysterious  influence  over  nervous  power. 
Thus  measles  not  unfrequently  excites  the  manifestations  of  a 
previously  latent  tubercular  tendency ;  scarlatina  and  measles  are 
apt  to  be  followed  by  obstinate  diarrhoea ;  and  diphtheria  is  some- 
times succeeded  by  a  loss  of  nervous  power,  usually  indeed  local, 
but  sometimes  general  and  sufficiently  serious  to  interfere  with  the 
working  of  all  the  functions  of  the  body. 

In  every  acute  disease  there  are,  therefore,  two  dangers :  the 
immediate  danger  and  the  remote  danger.  The  first  presses 
itself   upon  our    notice,  and    cannot  be  overlooked;    the  second 


DIMINISHED    NERVOUS    SENSIBILITY.  19 

obscured  by  distance,  is  apt  to  be  disregarded.  Acute  disease 
always  excites  attention  and  receives  immediate  treatment,  but  it 
is  not  enough  to  rest  satisfied  with  the  cessation  of  pressing 
symptoms.  There  is  always  the  danger  that  the  defective  nutri- 
tion, at  first  merely  temporary,  may  become  confirmed;  in  other 
words,  that  chronic  disease  may  be  established. 

One  consequence  of  the  weakly  condition  to  which  badly  nou- 
rished children  are  reduced  is  their  liability  to  secondary  acute 
diseases.  In  a  child  suffering  from  the  results  of-  chronic  inter- 
ference with  nutrition,  from  whatever  cause,  the  power  of  resist- 
ing new  injurious  influences  is  very  much  impaired.  In  such  a 
state  he  is  constantly  found  to  be  affected  by  causes  so  slight  as  to 
pass  almost  unnoticed,  and  which  in  a  healthy  child  would  be 
completely  powerless  to  do  harm.  If  the  emaciation  and  debility 
of  the  child  are  very  great,  these  secondary  diseases  may  give 
very  little  evidence  of  their  presence ;  for  an  infant  reduced  by 
mal-nutrition  to  a  cachectic  state  loses  many  of  the  vital  character- 
istics of  early  childhood,  especially  the  intense  excitability  of  the 
nervous  system  which  is  so  striking  a  peculiarity  of  healthy  in- 
fancy. In  a  robust  child  we  constantly  find  the  whole  system 
suffering  violently  from  sympathetic  derangement  set  up  by  some 
trifling  disturbance.  A  lump  of  indigestible  food,  or  a  slight  im- 
pression of  cold,  will  not  unfrequently  produce  burning  fever,  and 
alarming  nervous  symptoms,  as  delirium,  convulsions,  or  even  a 
state  approaching  to  coma.  On  the  other  hand,  in  an  infant  much 
reduced  by  long-continued  impairment  of  nutrition,  the  most  se- 
rious diseases  may  give  no  signs  of  their  presence.  Pneumonia 
may  exist  with  little  fever  and  no  cough,  and  a  serious  intestinal 
lesion  without  pain  and  with  only  trifling  diarrhoea. 

A  good  example  of  the  insensibility  of  the  nervous  system  to 
local  impressions  is  seen  by  attempting  the  well-known  experiment 
of  gently  stimulating  the  genito-crural  nerve,  described  by  Sir 
"William  Jenner  in  his  Lectures  on  Eickets.^  In  a  healthy  child 
the  finger-nail  drawn  lightly  along  the  upper  two-thirds  of  the 
inner  aspect  of  the  thigh  produces  an  instantaneous  rise  of  the 
testicle  of  that  side,  by  the  action  of  the  cremaster  muscle  which 
draws  it  up  close  to  the  external  abdominal  ring.  In  a  cachectic 
child  the  same  experiment  is  followed  by  no  result  whatever ;  the 

•  Medical  Times  and  Gazette,  March  17,  1860. 


20  INTRODUCTION". 

cremaster  does  not  contract,  and  the  testicle  remains  motionless. 
In  such  cases,  therefore,  there  is  absence  of  the  normal  excitability 
of  the  nervous  system  so  characteristic  of  healthy  infancy.  This 
insensibility  of  the  parts  of  the  nervous  system  concerned  in  the 
production  of  reflex  movements  is  further  indicated  by  the  infre- 
quency  of  reflex  convulsions  in  such  children.  In  well-nourished 
children  these  are  exceedingly  common,  and  the  natural  nervous 
sensibility  appears  to  be  heightened  by  anything  which  causes  a 
sudden  weakening  of  the  system,  as  severe  acute  diarrhcea,  or  great 
loss  of  blood.  When,  however,  the  debility  is  produced  more 
slowly,  the  same  result  does  not  follow,  and  the  excitability  of  the 
nervous  system,  instead  of  being  exalted,  is  more  or  less  completely 
destroyed. 

For  this  reason,  acute  diseases,  attacking  a  child  whose  nutrition 
is  thus  seriously  impaired,  have  a  character  all  their  own.  They 
are  distinguished  by  an  absence  of  those  peculiarities  which  we  are 
accustomed  to  consider  inseparable  from  the  disorders  of  childhood, 
and  resemble  more  the  same  diseases  as  they  occur  in  advanced 
age.  They  begin  more  insidiously  ;  run  their  course  more  slowly ; 
give  rise  to  fewer  symptoms ;  and  often  end  suddenly  and  unex- 
pectedly in  death.  Although  thus  undemonstrative,  they  are  not, 
however,  on  that  account  less  dangerous;  indeed,  the  prognosis 
may  be  said  to  be  serious  in  proportion  to  the  fewness  of  the 
symptoms  by  which  their  existence  is  announced.  By  offering  an 
additional  obstacle  to  nutrition  they  still  further  weaken  the 
already  enfeebled  constitution,  and  the  disease,  if  it  does  not  prove 
immediately  fatal,  is  apt  to  hang  on,  gradually  reducing  the  child 
more  and  more,  until  he  sinks  under  its  effects. 

It  is  difficult  to  over-estimate  the  importance  of  an  early  diag- 
nosis of  these  secondary  disorders.  On  account  of  their  insidious 
commencement  they  are  frequently  overlooked,  and  it  is  often  only 
by  the  more  rapid  debility  they  induce  that  suspicions  of  their 
existence  are  at  last  excited.  As  the  infant  is  unable  to  commu- 
nicate his  ideas  by  speech,  the  eye  should  be  practised  to  gather 
from  the  expression  and  gestures  of  the  child  the  information 
which  he  can  communicate  in  no  other  way.  A  careful  perusal  of 
the  face  is  therefore  of  the  utmost  importance.  By  it  we  can  as- 
certain the  existence  of  pain,  and  can  often  distinguish  the  part  of 
the  body  which  is  the  seat  of  serious  disease.  Thus,  pain  in  the 
head  is  indicated  by  contraction  of  the  brows ;  in  the  chest,  by  a 


jadelot's  "traits."  21 

sharpness  of  the  nostrils ;  and  in  the  belly,  by  a  drawing  of  the 
upper  lip. 

M.  Jadelot,  formerly  physician  to  the  Hopital  des  Bnfants  Trou- 
ves  at  Paris,  was  the  first  to  draw  attention  to  certain  "traits,"  or 
lines,  which  become  marked  on  the  face  of  a  child  suffering  from 
serious  disease,  and  the  situation  of  which  furnishes  indications  as 
to  the  part  of  the  body  to  which  it  is  necessary  to  direct  our  exa- 
mination. The  oculo-zygomatic  line,  or  furrow,  begins  at  the  inner 
angle  of  the  eye,  and  passing  outwards  underneath  the  lower  lid, 
is  lost  a  little  below  the  projection  formed  by  the  cheek-bone. 
This  indicates  disorder  of  the  cerebro-nervous  system,  becoming 
strongly  marked  in  all  those  diseases  whose  primary  seat  is  the 
brain  or  nerves,  or  in  cases  where  those  organs  become  affected 
secondarily  to  disease  commencing  in  other  parts. 

The  72asal  line  rises  at  the  upper  part  of  the  ala  of  the  nose,  and, 
passing  downwards,  forms  a  rough  semicircle  round  the  corner  of 
the  mouth.  Joining  this  at  an  angle  about  its  middle  is  another 
line,  called  genal,  which  reaches  from  that  point  almost  to  the 
malar  bone,  and  in  certain  faces  forms  the  dimple  of  the  cheek. 
These  indicate  disease  of  the  digestive  passages  and  the  abdominal 
viscera. 

The  labial  line  begins  at  the  angle  of  the  mouth,  and  is  directed 
outwards,  to  be  lost  in  the  lower  part  of  the  face.  It  is  seldom 
so  deep  as  the  preceding.  It  indicates  disease  of  the  lungs  and 
air-passages. 

M.  Jadelot  attributed  immense  importance  to  these  lines,  and 
even  stated  that  he  had  been  enabled  to  discover  the  exact  period 
at  which  the  cough  of  pertussis  assumed  its  convulsive  character 
by  the  appearance  of  the  oculo-zygomatic  line  upon  the  child's 
face.  Without,  however,  attaching  to  them  the  same  significance 
which  they  assumed  in  the  opinion  of  their  discoverer,  there  is  no 
doubt  that  they  often  furnish  important  indications,  and  are  there- 
fore, points  to  which  attention  should  always  be  directed  in  the 
examination  of  a  young  child. 

The  color  of  the  face  should  be  carefully  noted.  Lividity  of 
the  lips  and  of  the  eyelids  is  a  sign  of  imperfect  aeration  of  the 
blood,  or  may  indicate  digestive  disturbance,  or  merely  weak  cir- 
culation. A  peculiar  waxy-yellow  tint  is  seen  in  certain  parts  of 
the  face  in  inherited  syphilis ;  and  there  is  an  earthy  tinge  of  the 
face  and  whole  body  in  many  cases  of  chronic  bowel  complaint. 


22  INTRODUCTIOJSr. 

Exhaustion  is  indicated  by  coolness  and  pallor  of  the  face,  by  livi- 
dity  of  the  eyeballs  and  mouth,  and,  in  extreme  cases,  by  a  half 
closure  of  the  eyes,  so  as  to  leave  the  lower  parts  of  the  whites 
exposed,  while  at  the  same  time  the  fontanelle  is  deeply  depressed. 
The  state  of  the  fontanelle  should  be  always  examined,  for  it  forms 
a  very  important  guide  to  treatment ;  if  much  depressed,  stimu- 
lants should  never  be  withheld. 

The  breathing  must  be  watched.  If  rapid  and  accompanied  by 
movement  of  the  nares,  there  is  usually  bronchitis  or  pneumonia, 
and  a  careful  examination  of  the  chest  should  always  be  made. 
Unequal  movement  of  the  two  sides  of  the  chest  in  respiration 
generally  indicates  a  serious  lesion  on  the  side  at  which  the  move- 
ment is  least.  If  the  respiratory  action  of  the  abdominal  muscles 
be  increased,  attention  is  at  once  directed  to  the  chest.  If  the  belly 
be  motionless,  it  is  often  the  seat  of  an  inflammatory  complication. 

The  cry  of  the  infant  varies  very  much  in  character.  In  cere- 
bral affections  it  is  sharp,  short,  and  sudden.  In  lesions  of  the 
abdomen,  exciting  pain,  it  is  prolonged.  In  inherited  syphilis,  it 
is  high-pitched  and  hoarse.  In  inflammatory  diseases  of  the  larynx, 
it  is  hoarse,  and  may  be  whispering.  In  inflammatory  diseases  of 
the  lungs,  and  in  severe  rickets,  the  child  is  usually  quiet,  and  un- 
willing to  cry  on  account  of  the  action  interfering  with  the  respi- 
ratory functions. 

The  infant  should  always  be  completely  stripped  for  examina- 
tion. We  can  at  once  observe  the  form  and  play  of  the  chest,  the 
state  of  the  abdomen,  the  condition  of  the  skin,  whether  hot  or 
cool,  dry  or  moist,  and  the  conformation  of  his  limbs.  Besides, 
any  eruption  upon  the  skin  is  at  once  detected  by  this  means. 

The  large  size  of  the  belly  in  weakly  children  often  attracts  the 
attention  of  parents,  and  excites  much  anxiety.  It  is  most  com- 
monly produced  by  accumulation  of  flatus,  owing  to  the  weakness 
of  the  abdominal  walls.  It  may  be  also  due  to  displacement  of 
the  liver  and  spleen,  such  as  occurs  so  often  in  rickets  on  account 
of  the  depression  of  the  diaphragm  forcing  those  organs  dowwards 
from  beneath  the  cover  of  the  ribs.  The  liver  and  spleen  may  be 
themselves  enlarged ;  and  great  masses  of  cancer  occasionally 
spring  from  the  kidney  and  from  the  other  abdominal  organs.  As- 
cites may  be  present  from  tubercular  or  simple  peritonitis,  from 
Bright's  disease,  or,  rarely,  from  disease  of  the  liver.  Tubercular 
peritonitis  may  also  produce  extreme  tympanitis.     Accumulations 


CAUSES  OF  abdomi:n'al  enlargement.  23 

of  fecal  matters  may  take  place  in  sufficient  quantities  to  cause 
distension ;  and,  lastly,  the  mesenteric  glands  may  be  so  enlarged 
as  to  produce  a  visible  tumor.  Flatulence  is,  however,  as  has  been 
said,  by  far  the  most  frequent  cause  of  this  condition,  and  in  chil- 
dren reduced  by  chronic  disease  the  belly  is  almost  always  dis- 
tended from  this  cause.  The  bowels  are  in  such  cases,  usually  de- 
ranged ;  food  is  ill  digested ;  and  the  gas  set  free  by  decomposition 
of  the  starchy  matters  is  allowed,  through  the  feebleness  of  the 
muscular  walls,  to  accumulate  and  to  give  rise  to  much  discomfort 
and  swelling. 

It  is  of  great  importance  to  bear  in  mind  this  simple  cause  of 
the  enlargement,  for  a  big  belly  in  a  wasting  infant  is  constantly 
attributed  to  mesenteric  disease ;  and  it  is  not  uncommon  to  hear 
that  a  child  has  been  given  over  for  this  supposed  complaint  when 
he  is  in  reality  suffering  from  nothing  else  than  bad  feeding,  with 
derangement  of  the  bowels  as  its  natural  consequence.  Setting 
aside  the  general  rarity  of  mesenteric  disease,  and  its  extreme  rarity 
in  children  under  three  years  of  age,  there  remains  the  fact  that 
distension  of  the  abdomen  is  by  no  means  a  necessary  consequence 
of  this  disease.  On  the  contrary,  unless  the  glandular  disease  be 
great,  the  abdominal  wall  is  more  often  retracted  than  expanded.  It 
may  become  occasionally  distended  from  flatus,  as  in  all  cases 
where  the  bowels  are  disordered,  but  the  distension  is,  in  such 
cases,  independent  of  the  affection  of  the  glands,  and  is  merely  an 
accidental  complication.  If  the  increase  in  size  of  the  glands  is 
sufficiently  great  to  produce  a  distinct  tumor,  the  swelling  is 
seated  about  the  umbilicus,  and  does  not  occupy  the  whole  abdo- 
men. In  all  cases,  therefore,  where  the  belly  is  swollen  uniformly, 
the  probabilities  are  very  strongly  against  mesenteric  disease ;  and 
if  no  tumor  can  be  detected  on  pressure  in  the  situation  of  the 
glands,  no  foundation  exists  for  attributing  the  enlargement  of  the 
abdomen  to  this  cause.  For  fuller  information  upon  this  subject 
the  reader  is  referred  to  the  article  on  Mesenteric  Phthisis,  where 
will  also  be  found  the  method  of  distinguishing  this  disease  from 
accumulations  of  fecal  matter  in  the  color. 

The  size  of  the  liver  and  spleen  should  always  be  investigated. 
The  extent  of  liver-dulness  should  be  estimated  by  percussion.  If 
the  organ  descends  below  the  level  of  the  ribs,  the  hand  should  be 
laid  fiat  upon  the  belly ;  by  gentle  palpation  with  the  ends  of  the 
fingers  we  can  then  always  feel  the  thin  border,  and,  unless  the 


24  INTRODUCTION. 

abdominal  wall  be  very  tense,  can  generally  succeed  in  inserting 
the  tips  of  the  fingers  underneath  the  sharp  edge. 

The  size  of  the  spleen  is  very  easily  estimated.  The  fingers  of 
the  right  hand  are  placed  at  the  back,  directly  below  the  twelfth 
rib,  and  just  outside  the  mass  formed  by  the  lumbar  muscles;  the 
fingers  of  the  left  hand  are  placed  exactly  opposite  the  former,  in 
front  of  the  belly;  by  pressing  the  two  hands  towards  one  another, 
the  spleen,  if  it  is  enlarged,  is  caught  between  them.  If  the  hands 
have  been  rightly  applied,  and  the  spleen  is  not  felt,  it  may  be  con- 
sidered to  be  of  natural  size. 

It  must  be  remembered,  however,  that  both  these  organs  may  be 
felt  more  readily  than  is  natural  without  being  necessarily  enlarged, 
as  they  may  be  displaced  bj'  pressure  of  the  diaphragm. 

In  the  treatment  of  chronic  wasting  in  a  young  child  our  first 
care  should  be  to  remove  any  derangement  of  the  stomach  and 
bowels.  For  this  object  a  strict  regulation  of  his  diet  is  indis- 
pensable. In  the  great  majority  of  such  cases  the  cause  can  be 
distinctly  traced  to  improper  feeding,  and  therefore  an  alteration 
in  the  diet  is  the  first  step  to  a  cure.  Tonics  given  to  a  child 
whose  bowels  remain  disordered  are  perfectly  useless,  for,  so  long 
as  the  derangement  of  the  alimentary  canal  continues,  nutrition 
cannot  be  restored  on  account  of  the  impediment  thus  presented 
to  the  digestion  and  assimilation  of  food. 

Directions  on  the  subject  of  diet  cannot  be  too  precise ;  it  is 
necessary  to  state  distinctly,  not  only  the  articles  of  food  to  be 
given,  but  the  quantities  to  be  allowed  at  each  meal,  and  the  fre- 
quency with  which  the  meals  are  to  be  repeated.  It  is  advisable 
to  write  down  all  such  directions,  that  misunderstanding  may  be 
avoided ;  in  fact,  the  same  attention  should  be  paid  to  this  subject 
as  is  paid  to  the  ordering  of  drugs. 

After  the  diet  has  been  altered  to  suit  the  requirements  of  the 
case,  more  special  treatment  is  called  for,  and  the  means  at  our 
command  may  be  divided  into  two  classes,  viz.,  external  applica- 
tions, and  internal  remedies. 

External  applications  are  of  great  service  in  all  chronic  diseases, 
for  it  is  important  to  restore  as  quickly  as  possible  the  healthy 
action  of  the  skin.  For  this  purpose,  frictions,  counter-irritants, 
and  baths,  hot  or  cold,  may  be  used. 

Frictions  can  be  employed  with  the  hand  alone,  with  stimulating 
liniments,  or  with  cod-liver  oil.     By  this  means  the  circulation  is 


EXTERNAL    USE    OF    OIL.  25 

rendered  more  vigorous,  and  the  action  of  the  skin  is  promoted. 
The  feebleness  of  the  circulation  in  most  cases  of  chronic  disease 
in  the  infant  is  shown  by  the  coldness  of  the  extremities.  When 
these  have  been  warmed  by  suitable  applications,  the  beneficial 
influence  is  often  very  decided;  pain  in  the  belly  ceases,  and  the 
child  usually  falls  into  a  quiet  sleep.  The  frictions  should  be  used 
to  the  whole  body  if  there  is  no  tenderness.  In  cases  of  rickets, 
however,  this  cannot  at  first  be  borne,  as  in  that  disease  there  is 
extreme  tenderness,  which  renders  the  least  movement  or  pressure 
painful  to  the  child.  When,  however,  the  disease  is  improving, 
frictions  are  exceedingly  useful,  and  should  never  be  neglected. 
Friction  with  stimulating  liniments  is  merely  a  mild  form  of  coun- 
ter-irritation which  can  be  applied  generally,  and  has  a  more  pow- 
erful influence  in  stimulating  the  circulation  and  promoting  a  flow 
of  blood  to  the  surface  than  friction  with  the  hand  alone.  It  is 
useful  in  all  cases  where  the  debility  is  great. 

Friction  with  cod-liver  oil  is  valuable  as  a  means  of  intro- 
ducing nourishment  into  the  sj'^stem,  and  when  the  irritability  of 
the  stomach  is  great  this  is  a  very  useful  means  of  administering 
the  oil. 

Oily  frictions,  or  the  mere  application  of  oil  to  the  surface  of  the 
body,  has,  however,  another  purpose  than  that  of  supplying  nou- 
ris-hment.  When  the  oil,  slightly  warmed,  is  smeared  over  the 
whole  body  with  a  piece  of  fine  sponge,  and  the  child,  wrapped  in 
flannel,  is  afterwards  placed  in  his  bed  or  cot,  one  of  the  first 
effects  noticed  is  a  profuse  general  perspiration.  This  is  accom- 
panied sometimes  by  a  little  erythematous  eruption,  which  resem- 
bles the  rash  of  measles.  At  the  same  time,  any  irritability  of  the 
nervous  system  is  quieted,  and  the  child  soon  falls  into  a  tranquil 
sleep.  A  third  effect  is  an  increase  in  the  quantity  of  all  the 
secretions :  the  urine  is  more  abundant,  and  the  functions  of  the 
liver  appear  to  be  rendered  more  active,  for,  according  to  the 
observations  of  Bauer,  of  Tubingen,  the  stools,  from  being  green 
and  sour-smelling,  become  yellow  and  natural. 

To  produce  these  effects,  it  is  not  essential  that  cod-liver  oil  be 
employed :  other  oils  will  be  found  equally  efficacious,  and  are, 
indeed,  generally  to  be  preferred,  on  account  of  the  disagreeable 
smell  of  the  fish  oil,  which  is  often  a  source  of  discomfort.  On 
account  of  its  influence  in  promoting  the  action  of  the  skin,  anoint- 


26  INTRODUCTION. 

ing  with  oil  is  of  great  service  in  all  the  diseases  which  are  here 
treated  of,  and  in  cases  where  the  weakness  and  emaciation  are 
extreme,  the  most  striking  results  sometimes  follow  the  applica- 
tion if  it  be  repeated  with  sufficient  perseverance.  A  warm  bath, 
or  a  thorough  sponging  of  the  whole  body,  with  very  warm  water, 
immediately  before  the  oil  is  applied,  is  useful  in  preparing  the 
skin  for  the  action  of  the  oil,  and  greatly  increases  the  effects. 

In  the  application  of  counter-irritants  to  young  children,  great 
care  must  be  taken  not  to  carry  the  counter-irritation  too  far.  An 
irritant  which,  in  a  healthy  child,  would  produce  only  a  moderate 
degree  of  redness,  will  often,  where  the  strength  is  much  reduced, 
set  up  very  great  inflammation,  or  even  produce  sloughing  of  the 
tissues.  Such  a  result  would  not  only  still  further  reduce  the 
child's  little  remaining  strength,  but  would  act  as  a  direct  irritant 
to  the  part  for  which  it  is  intended  to  be  a  derivative.  For  this 
reason  counter-irritation  should,  as  a  rule,  be  general  rather  than 
local,  being  employed  in  the  form  of  stimulating  liniments  and  hot 
baths.  Sometimes,  however,  a  local  counter-irritant  is  required. 
In  these  cases  equal  parts  of  flour  of  mustard  and  linseed  meal 
should  be  used.     Blisters  are  inadmissible  for  infants. 

For  the  hot  bath,  the  water  should  be  of  the  temperature  of 
from  95°  to  100°  Fahr.,  and  should  be  sufficient  in  quantity  to 
cover  the  child  up  to  the  neck.  After  remaining  in  the  water  for 
three,  four,  or  five  minutes,  he  should  be  quickly  but  thoroughly 
dried,  and  be  then  wrapped  in  flannel  and  returned  to  his  cot.  It 
is  of  great  importance  that  he  should  not  be  left  too  long  in  the 
hot  water.  The  effect  of  the  hot  bath  is  at  first  stimulating,  but 
after  stimulation  comes  reaction,  and  depression  is  induced.  He 
must  be,  therefore,  removed  before  the  stimulating  effect  has  had 
time  to  pass  off.  Children,  especially  when  unwell,  often  show 
great  repugnance  to  the  bath,  and  become  much  terrified  at  the 
sight  of  the  water.  In  these  cases  it  is  convenient  to  cover  the 
bath  with  a  blanket ;  the  child,  being  placed  upon  this,  can  be 
lowered  gently  down  into  the  water  without  seeing  anything  to 
excite  his  apprehensions. 

Sometimes  a  more  powerful  stimulant  is  required.  In  these  cases 
the  child  should  be  wrapped  in  flannel  wrung  out  of  hot  water,  and 
upon  which  some  flour  of  mustard  has  been  sprinkled;  the  whole 
being  covered  with  a  dry  warm  blanket.     Or  the  mustard  bath 


BATHS  —  TONICS.  27 

recommended  by  the  late  Prof.  Trousseau  may  be  adopted.^  For 
this,  some  flour  of  mustard  is  mixed  with  cold  water,  and  is  put 
into  a  linen  bag.  The  bag  is  then  squeezed  in  the  bath,  and  the 
water  becomes  strongly  sinapized.  The  child  is  held  in  the  warm 
water  until  the  arms  of  the  person  supporting  him  begin  to  prick 
and  tingle.  The  quantity  of  mustard  required  for  this  bath  is  in 
the  proportion  of  two  ounces  to  five  gallons  of  water. 

The  immediate  effect  of  the  cold  bath  is  directly  contrary  to  that 
of  the  hot  bath.  Its  first  effect  is  depressing,  on  account  of  the 
shock.  In  a  few  seconds,  however,  reaction  succeeds  to  the  tem- 
porary depression,  the  surface  of  the  body  glows,  and  the  pulse 
becomes  fuller  and  stronger.  It  acts,  therefore,  as  a  general  stimu- 
lant and  tonic,  promoting  nutrition,  and  giving  tone  to  the  body. 
If  continued  too  long,  reaction  subsides,  and  there  is  a  sense  of 
chilliness  and  languor,  with  loss  of  appetite,  which  may  last  for 
several  hours.  The  shock  is  great  in  proportion  to  the  coldness  of 
the  water,  and  the  degree  of  weakness  of  the  patient.  The  addi- 
tion of  salt  to  the  water  makes  it  more  stimulating,  and  increases 
the  vigor  of  the  reaction. 

On  account  of  these  effects  the  cold  bath  should  be  used  with 
caution,  and  is  inadmissible  until  the  child  is  far  advanced  towards 
convalescence.  It  then  becomes  a  valuable  means  of  invigorating 
the  system.  The  water  should  not  at  any  time  be  below  the  tem- 
perature of  60°  Fahr,,  and  should  be  used  tepid  at  the  first,  the 
temperature  of  succeeding  baths  being  gradually  reduced  as  the 
child  gets  stronger.  Any  chilliness  or  languor  after  the  bath  are 
signs  that  too  cold  water  has  been  used,  or  that  the  bath  has  been 
continued  too  long.  To  be  beneficial,  the  whole  process  should  be 
rapid.  The  child  should  be  quickly  sponged,  and  should  then  be 
dried  briskly  with  a  thick  soft  towel.  The  whole  body  should  be 
afterwards  well  and  firmly  rubbed  with  the  open  hand  to  assist  the 
reaction. 

Of  internal  remedies  little  need  be  said  in  this  place,  as  full  di- 
rections will  be  given  afterwards  in  considering  the  treatment  of 
the  different  diseases.  The  important  point  to  remember  is  the 
uselessness  of  tonics  so  long  as  any  derangement  of  the  digestive  or- 
gans remains  uncorrected.  In  order  that  tonics  may  be  beneficial, 
the  stomach  and  bowels  must  be  in  a  healthy  state.     It  is  only 

'  Clinique   M6dioale. 


28  INTRODUCTION. 

when  digestion  is  restored  that  these  remedies  are  admissible ;  they 
will  then  prove  of  extreme  service,  increasing  the  vigor  of  the 
stomach,  and  improving  the  tone  of  the  whole  body. 

To  the  general  list  of  tonics,  cod-liver  oil  is  an  important  addi- 
tion. It  is,  indeed,  more  a  food  than  a  medicine;  but  for  this  very 
reason  it  should  not  be  given  in  too  large  quantities.  If  more  of 
the  oil  is  being  taken  than  can  be  digested,  the  surplus  passes 
down  through  the  bowels,  and  is  seen  unchanged  in  the  stools, 
where  it  is  at  once  recognized  by  its  appearance  and  smell.  In  ad- 
ministering the  oil  our  object  should  be  to  give  as  much  as  can  be 
readily  digested,  but  no  more.  For  a  child  under  two  years  of 
age,  ten  drops  will  be  a  sufficient  dose  at  the  first.  The  quantity, 
after  the  first  few  days,  can  be  gradually  increased,  but  a  careful 
watch  must  be  kept  upon  the  stools,  and  the  appearance  of  any  oil 
unchanged  in  the  evacuations  is  a  sign  that  the  quantity  must  be 
reduced.  For  a  child  of  this  age  we  can  seldom  go  beyond  thirty 
drops  for  the  dose,  three  times  in  the  day.  It  must  always  be  re- 
membered that  the  oil  is  an  addition  to,  not  a  substitute  for  other 
food,  and  is  therefore  only  useful  so  long  as  it  is  well  borne  by  the 
stomach.  If  it  be  found  to  impair  the  appetite,  or  to  interfere  in 
the  slightest  degree  with  digestion,  its  use  should  be  immediately 
discontinued. 

"With  regard  to  stimulants;  they  are  always  required  when  the 
fontanelle  becomes  much  depressed.  The  best  form  is  pale  brandy, 
of  which  a  few  drops  (five  to  ten)  may  be  given  in  cold  water  or  a 
little  milk,  as  often  as  circumstances  seem  to  demand  the  repetition. 


CHAPTER    I. 

SIMPLE   ATEOPHY  FKOM   INSUFFICIEXT  NOURISHMENT. 

Simple  Ateophy  from  Insufficient  Nourishment. — An  exceedingly  common  con- 
dition.— Causes — Insufficient  supply  of  food — Varieties  of  breast  milk — Ef- 
fect of  preponderance  of  butter  in  the  milk — Test  of  a  good  nurse — Unsuitable 
food — Dependence  of  nutrition  upon  power  of  digestion — Over-feeding — 
Varieties  of  food  required  for  perfect  nutrition — DiflFerences  between  woman's 
and  cow's  milk — Cow's  milk  cannot  always  be  digested. 

Syinptoms. — Two  classes,  according  to  cause — Food  suitable  but  insufficient — 
Food  unsuitable — Wasting — Constipation — Cause  of  inactivity  of  bowels — 
Flatulence — Colic — Ravenous  appetite — Eruptions  on  skin,  strophulus  and 
urticaria — Thrush,  its  importance  in  prognosis — Inward  fits — Attacks  of  vomit- 
ing and  diarrhoea — Convulsions — Aphthae — Danger  of  secondary  diseases — 
Mode  of  death. 

Treatment. — Suckling — By  mother — By  nurse — Rules  for  choosing  nurse — Direc- 
tions for  efficient  suckling — Advantages  of  putting  child  early  to  breast  after 
birth — Times  of  suckling — Artificial  feeding — Directions — Feeding  bottle — 
Importance  of  cleanliness — Different  infants'  foods — Liebig's  food — Cow's 
milk  may  disagree — Weaning — Usual  time — Must  sometimes  be  anticipated 
— Method  of  weaning — Reason  why  a  child  may  refuse  the  breast — Diet  after 
weaning — General  management  of  infants — Treatment  of— Constipation — 
Flatulence  and  colic — Convulsions — Thrush — Aphthae — Diarrhoea  and  vomit- 
ing. 

This  is  the  commonest  form  of  disease,  and  the  most  frequent 
cause  of  death  in  infants.  Many  thousand  children  die  yearly  in 
Loudon  alone  for  the  simple  reason  that  tbey  are  fed  systematically 
and  persistently  upon  food  which  they  cannot  digest.  And  so 
long  as  the  children  of  the  poor  are  allowed  to  leave  their  schools 
utterly  uninformed  as  to  duties  which  in  after  life  they  will  be 
called  upon  to  fulfil,  so  long  this  dreadful  mortality  may  be  ex- 
pected to  continue. 

Causes. — The  supply  of  food  may  be  actually  insuflficient.  This 
is  found  in  cases  where  the  child  is  nourished  entirely  by  the 
breast,  and  the  milk  of  the  mother  is  poor  and  watery  ;  or  in  those 
cases  where  the  breast  has  remained  the  sole  support  of  the  child 
after  the  time  when  some  other  food  ought  to  have  been  given  in 


30  SIMPLE    ATROPHY. 

addition.  "When  the  mother  is  weak,  anemic,  and  evidently  ill- 
nourished,  her  milk  no  doubt  always  suffers  from  the  impoverished 
state  of  her  blood ;  but  the  converse  of  this  is  not  always  the  case, 
for  the  milk  of  a  woman  may  still  be  of  very  inferior  quality, 
although  in  her  health  and  general  appearance  she  may  present  no 
sign  of  weakness.  From  the  researches  of  MM.  Yernois  and  Bec- 
querel  ^  we  find  that  the  richest  milk  is  far  from  being  secreted  by 
women  of  the  greatest  muscular  development.  On  the  contrary, 
their  investigations  tend  to  show  that  a  robust  figure  is  inferior  in 
milk-producing  power  to  one  slighter  and  less  apparently  vigor- 
ous. The  following  table,  formed  after  an  analysis  of  sixty-three 
cases  of  the  former,  and  twenty-three  of  the  latter,  will  make  this 
apparent.  Under  the  first  head  (strong  constitution)  they  place 
brunettes,  with  well-developed  muscles,  fresh  complexions,  moder- 
ate plumpness,  and  all  the  other  external  signs  of  constitutional 
strength.  Under  the  second  head  they  range  fair-complexioned 
women,  with  light  or  red  hair,  flabby  muscles,  and  sluggish  mus- 
cular contraction. 

strong  Weak 

Constitution.  Constitution.  Normal. 

Specific  grav 1032.97  1031.90  1032.(57 

Water 911.19  887.59  889.08 

Solid  parts 88.81  112.41  110.92 

Sugar        32.55  42.88  43.64 

Casein       28.98  39.21  39.24 

Butter 25.96  28.78  26.66 

Salts         1.32  1.54  1.38 

It  will  thus  be  seen  that  in  women  ranked  under  the  head  of 
strong  constitution  the  deficiency  in  the  amount  of  the  sugar  and 
the  casein  is  very  remarkable,  while  in  those  of  apparently  weaker 
constitution  these  elements  very  nearly  attain  the  normal  standard. 

There  is  another  condition  of  the  milk  which  appears  to  exercise 
a  great  influence  upon  the  health  of  the  nursling.  Out  of  89 
infants  suckled  by  women  in  apparently  good  condition  fifteen 
were  found  by  MM.  Vernois  and  Becquerel  to  be  inefficiently 
nourished.  On  a  careful  analysis  of  the  milk  it  was  found  that  in 
all  these  cases  the  relative  proportion  of  the  butter  was  raised 
considerably  above  the  normal  standard,  being  on  an  average 
33.22  against  26.66,  the  healthy  amount,  while  the  proportions  of 
the  casein  and  the  sugar  remained  unaltered. 

>  "Du  Lait  Chez  la  Femme."     8vo.     Paris,  1853. 


UNSUITABLE    FOOD.  31 

For  practical  purposes,  we  may  make  a  guess  at  tlie  quantity 
and  quality  of  the  milk  by  inspection  of  the  breasts  of  the  mother 
or  nurse.  They  should  be  pear-shaped,  hardish,  and  mottled  with 
blue  veins.  On  pressure  of  the  gland  the  milk  should  squirt  out. 
The  milk  itself  should  be  opaque  and  of  a  dull  white  color  :  under 
the  microscope  it  should  present  fat  globules  of  medium  size,  not 
too  small.  As  a  rule,  the  number  of  the  fat  globules  is  a  rough 
indication  of  the  quantity  of  casein  and  sugar,  although  this,  as 
has  been  said,  is  not  always  a  trustworthy  guide.  The  best  test, 
however,  of  the  goodness  of  the  milk  is  derived  from  observation 
of  the  child.  He  should  be  watched  while  at  the  breast,  and  if  he 
sucks  vigorously,  finishes  the  meal  with  the  milk  running  over  his 
lips,  and  requires  suck  but  a  few  times  in  the  day,  we  may  infer 
that  the  milk  is  sufficiently  abundant.  If,  on  the  other  hand,  he 
constantly  requires  the  breast,  sucks  laboriously  and  with  effort, 
occasionally  desisting  and  crying  peevishly,  the  milk  is  probably 
scanty.  As  an  additional  test  the  infant  may  be  weighed  immedi- 
ately before  and  after  taking  the  breast :  the  increase  in  weight 
should  be  from  three  to  six  ounces,  according  to  his  age. 

Besides  the  above  cases,  where  the  quantity  of  the  food  is  at 
fault,  there  is  another  class  of  cases  where  nutrition  is  equally 
unsatisfactory,  although  the  supply  of  food,  as  food,  is  liberal 
enough.  These  cases  occur  where  weaning  is  premature,  or  where 
the  child  has  been  brought  up  by  hand,  and  the  kind  of  food 
chosen  to  replace  the  natural  nourishment  is  injudiciously  selected, 
so  that  the  limited  digestive  power  of  the  child  is  unable  to  con- 
vert it  into  material  necessary  for  the  growth  and  development  of 
the  tissues.  Here  the  diet  substituted  for  the  mother's  milk, 
although  nutritious  enough  in  itself,  yet  supplies  little  nutriment 
to  the  infant.  A  child  is  not  nourished  in  proportion  to  the  bulk 
of  the  food  he  receives  into  his  stomach.  He  is  only  nourished  by 
the  food  he  can  digest.  Weakness  in  a  child  otherwise  healthy, 
while  it  shows  a  deficient  degree  of  nutrition,  and  therefore  calls 
for  an  increased  supply  of  nourishment,  yet  at  the  same  time  calls 
for  increased  care  in  the  selection  of  the  kind  of  food.  There  is  a 
difference  between  food  and  nourishment.  A  child  may  take 
large  quantities  of  food  into  his  stomach,  and  yet  from  weakness 
of  his  digestive  organs,  or  from  the  indigestible  nature  of  the  food 
swallowed,  may  derive  no  nourishment  from  it  whatever.  On  the 
contrary,  it  may  cause  great  irritation  and  pain  in  the  alimentary 


32  SIMPLE    ATROPHY. 

canal,  and,  setting  up  a  febrile  state,  still  further  reduce  the  child 
whom  it  was  intended  to  support.  The  tendency  of  mothers  is  to 
overfeed  their  children — to  mistake  every  cry  for  the  cry  of  hunger. 
Consequently,  as  the  peevishness  and  irritability  of  the  child  in- 
crease in  proportion  to  the  pain  excited  in  the  bowels,  the  food  is 
made  more  and  more  "  nourishing ;"  the  louder  the  cry  the  thicker 
the  "  sop,"  until  at  last  a  violent  attack  of  vomiting  or  of  diarrhoea 
takes  place,  or  a  convulsive  fit  warns  the  parent  that  it  is  time  to 
desist.  Cases  of  steady  emaciation  will  be  constantly  found  due 
to  this  cause,  especially  in  children  who  are  brought  up  by  hand. 
Amongst  the  poorer  classes  they  are  commonly  fed  upon  fari- 
naceous food  as  soon  as  they  are  born.  This,  of  course,  they  are 
totally  unable  to  digest.  As  a  consequence,  they  dwindle  and 
rapidly  die,  or,  if  of  particularly  robust  constitution,  linger  on, 
weak,  ailing,  and  rickety,  until  an  attack  of  bowel  complaint,  or 
other  intercurrent  disease,  carries  them  off".  The  very  fact  that 
the  secretion  of  saliva  in  the  young  child  does  not  become  esta- 
blished until  the  third  month  after  birth,  seems  to  indicate  that 
before  that  age  farinaceous  articles  of  diet  are  unsuited  to  the  infant, 
as  saliva  is  one  of  the  most  important  agents  in  the  digestion  of 
starchy  foods.  Besides,  for  perfect  nutrition  four  classes  of  foods 
are  required — viz.,  albuminates,  fatty  substances,  carbo-hydrates, 
and  salts.  These  are  found  in  the  most  digestible  form  and  the 
most  perfect  proportions  for  the  young  child  in  the  casein,  butter, 
sugar,  and  salts  of  the  human  milk.  The  casein  supplies  the  waste 
of  the  nitrogenous  tissues,  as  the  muscles,  and  probably  the  brain 
and  nerves,  and  by  its  oxidation,  when  it  has  formed  part  of  these 
tissues,  contributes  also  to  animal  heat.  The  butter  is  essential  to 
the  formation  of  muscular  and  nervous  tissues,  and  also  aids  by  its 
oxidation  in  the  production  of  heat.  The  sugar  is  probably  en- 
tirely heat-giving.  The  salts  form  the  necessary  constituents  of 
all  tissues. 

In  nutrition,  it  is  important  that  tissue  change  should  be  rapid, 
and  in  young  children,  where  development,  as  well  as  growth,  is 
so  brisk,  this  is  of  especial  importance.  It  is  effected  by  the  oxi- 
dation of  old  material,  which  is  then  removed,  to  be  replaced  by 
new  matter.  For  rapid  change,  therefore,  it  is  indispensable  that 
no  needless  impediment  should  exist  to  the  free  oxidation  of  the 
tissues.  Now,  starches,  and  sugars  into  which  the  starches  are 
converted  by  digestion,  have  a  greater  affinity  for  oxygen  than 


woman's  milk  and  cow's  milk  compared.      33 

albuminates;  thej,  therefore,  tend  to  appropriate  the  oxygen  which 
is  reoj' uired  for  the  removal  of  waste  matters,  and  so  to  prevent  the 
proper  changes  from  taking  place.  For  this  reason  alone,  and 
without  any  refereace  to  their  indigestible  properties,  they  form  a 
very  unsuitable  diet  for  a  young  child. 

Even  those  children  who  are  fed  entirely  upon  cow's  milk  are 
not  free  from  danger.     By  referring  to  the  table'  we  see  that  the 


Specific 
gravity. 

Water. 

Solids. 

Sugar. 

Casein. 

Butter. 

Salts. 

Woman's  milk 

1032.67 

889.08 

110.92 

43.64 

39.24 

26.66 

1.38 

Cow's  milk  . . . 

1033.38 

864.06 

135.94 

38.03 

55.15 

36.12 

6.64 

specific  gravity  of  cow's  milk  is  higher  than  that  of  woman's  milk, 
and  that  it  contains  a  larger  quantity  of  solid  matters,  owing  prin- 
cipally to  an  increase  in  the  amount  of  casein.  On  the  other  hand, 
the  proportion  of  sugar  is  less  than  that  found  in  human  milk.  In 
adapting  it,  therefore,  as  a  substitute  for  the  natural  food  of  the 
child,  it  will  be  necessary  to  remedy  these  differences  by  dilution 
with  water,  and  by  the  addition  of  a  small  quantity  of  sugar  of 
milk.  But  this  is  not  enough.  There  is  another  distinction 
between  the  two  fluids  which  it  is  extremely  important  to  take 
into  consideration.  On  the  addition  of  rennet,  the  casein  of  human 
milk  coagulates  into  light,  loose  clots,  formed  by  the  aggregation 
of  little  flocculi,  while  that  of  cow's  milk  congeals  inio  heavy  com- 
pact lumps.  The  same  thing  takes  place  in  the  stomach  of  the 
child,  as  is  shown  by  producing  vomiting  in  an  infant  directly  after 
a  meal  by  friction  over  the  belly  ;  the  light  loose  clots  formed  from 
human  milk  are  then  readily  distinguishable  from  the  dense  masses 
of  casein  produced  by  coagulation  of  the  milk  of  the  cow.  The 
difference  in  the  digestibility  of  these  two  products  is  very  evident. 
While  the  one  is  readily  assimilated  without  any  undue  demand 
upon  the  digestive  powers,  the  other  tasks  these  powers  to  the 
utmost,  and,  unless  a  very  moderate  quantity  have  been  taken,  will 
undergo  fermentation,  and  give  rise  to  much  flatulence,  colic,  and 
perhaps  diarrhoea  in  its  progress  along  the  alimentary  canal. 

Children  are,  no  doubt,  frequently  found  to  thrive  upon  this  diet, 
their  digestive  power  being  equal  to  the  demands  made  upon  it. 
Others,  however,  and  by  far  the  larger  proportion,  are   not  equal 

'  Vernois  and  Becquerel,  loc.  cit. 


34  SIMPLE    ATROPHY. 

to  this  daily  call  upon  their  powers.  They  oannot  assimilate  this 
mass  of  curd.  Consequently,  unless  rejected  by  vomiting,  it 
passes  through  them  undigested  ;  their  wants  are  not  supplied ; 
and  they  starve  for  lack  of  nourishment,  although  swallowing 
every  day  a  quantity  of  milk  which  would  be  ample  support  to  a 
much  stronger  and  healthier  infant.  Such  children  are  exceed- 
ingly restless  and  irritable.  They  cry  day  and  night ;  at  one  time 
from  abdominal  pains  excited  by  the  presence  in  the  bowels  of 
this  undigested  mass ;  at  others,  from  the  hunger  which  the  pas- 
sage of  this  meal  has  failed  to  appease.  The  nurses  say,  very 
truly,  that  the  "child  is  ravenous,"  and  that  "the  milk  does  not 
satisfy  him;"  but  the  baked  flour,  the  infant's  biscuits,  and  the 
tops  and  bottoms  by  which  they  propose  to  themselves  to  attain 
that  end,  are  by  no  means  calculated  to  do  so.  Instead  of  miti- 
gating his  distress,  they  aggravate  it ;  and  every  additional  meal, 
although  it  may  quiet  him  for  the  time,  yet,  by  the  discomfort 
which  it  is  certain  to  produce,  forms  a  subject  for  future  com- 
plaints. It  is,  however,  often  very  difficult  to  persuade  mothers 
and  nurses  of  the  importance  of  what  has  been  stated.  They  see 
that  the  child  is  wasting  under  the  diet  they  have  first  adopted, 
and  therefore  will  not  but  infer  that  something  more  solid  must  be 
required.  It  is  necessary  to  impress  upon  them  very  strongly 
that  a  child  may  actually  starve  on  the  fullest  diet,  and  that  the 
presence  of  large  quantities  of  farinaceous  or  caseous  matters  in 
the  alimentary  canal  is  not  necessarily  followed  by  any  additional 
supply  of  nourishment  to  the  tissues.  In  all  cases  where  the  food 
of  an  infant  is  said  by  nurses  to  be  insufficient,  the  stools  should 
be  carefully  examined,  and  if,  as  is  so  frequently  the  case,  they  are 
found  to  consist  of  pale,  round,  hardish  lumps,  exhibiting  in  their 
interior  the  cheesy  appearance  so  characteristic  of  a  mass  of  curd, 
we  may  safely  conclude  that  it  is  not  that  too  little  is  being  given, 
but  too  much ;  and  by  taking  the  necessary  precautions,  we  may 
succeed  in  providing  the  child  with  a  diet  he  is  capable  of  digesting. 

Besides  the  weakness  produced  by  the  withholding  of  nourish- 
ment, there  is  an  additional  cause  of  debility  in  the  constant  attacks 
of  vomiting  and  diarrhoea  to  which  this  indigestible  diet  invariably 
leads.  Each  of  these  attacks  reduces  him  more  and  more,  and  by 
weakening  his  digestive  power  renders  him  less  than  ever  able  to 
obtain  any  nourishment  from  the  food  with  which  he  is  supplied. 

Synqytoms. — The  symptoms  of  simple  wasting  from  insufficient 


SYMPTOMS.  35 

nourishment  may  be  divided  into  two  classes,  according  to  the 
nature  and  quantity  of  the  food  taken  : — 

Food  suitable,  but  insufficient. 

Food  unsuitable. 

In  the  first  of  these  classes  there  are  no  very  striking  symptoms. 
The  infant  gradually  loses  his  plumpness;  his  fat  slowly  disap- 
pears; and  the  muscles  get  very  flaccid  and  soft.  He  does  not 
seem  to  grow.  His  face  becomes  pale,  and  his  lips  pale  and  thin. 
He  is  peevish  as  a  consequence  of  his  hunger ;  takes  the  breast 
ravenously  at  the  first,  and  then,  if  the  secretion  of  milk  is  scanty, 
desists  at  intervals  to  cry  passionately  as  if  in  vexation  at  his  in- 
ability to  obtain  the  means  of  satisfying  his  wants.  His  skin  is 
moist,  and  he  perspires  readily  and  copiously.  The  fontanelle  is 
level  or  slightly  depressed.  At  night  he  is  exceedingly  irritable, 
and  sleepless.  In  the  day-time  he  will  often  lie  quietly  enough, 
holding  both  thumbs  in  his  mouth,  and  sucking  at  them  until  the 
skin  at  the  sides  of  the  nail  becomes  raw  and  abraded.  If  the 
milk  is  poor  but  abundant,  the  child  is  usually  very  quiet  and 
drowsy,  passing  almost  all  his  time  asleep.  He  may  even  sleep 
while  at  the  breast — a  sure  sign  that  the  milk  is  thin  and  serous. 
The  bowels  are  usually  confined,  and  the  motions  rather  solid, 
although  otherwise  natural.  No  symptoms  are  found  to  indicate 
disease  of  any  particular  part  of  the  body. 

In  this  class  of  cases  nutrition  is  defective  on  account  of  the 
inferior  quality  and  insufficient  quantity  of  the  mother's  milk,  and 
nothing  is  added  to  compensate  lor  these  defects.  The  remedy  is, 
of  course,  to  supply  the  deficiency.  When  the  required  nourish- 
ment is  given,  the  wasting  stops  at  once,  the  peevishness  ceases, 
and  the  child,  rapidly  regaining  flesh,  becomes  strong  and  healthy. 

In  the  second  class  of  cases,  where  the  food  is  bad  in  quality, 
we  find  the  symptoms  of  defective  nutrition  combined  with  other 
symptoms  produced  by  the  irritation  of  the  digestive  organs  to 
which  the  presence  of  indigestible  food  necessarily  gives  rise.  The 
child  is  dull  and  languid,  his  flesh  becomes  flabby,  and  he  begins 
to  waste.  The  skin  is  moist,  at  the  first,  although  afterwards  it  is 
apt  to  become  dry,  except  about  the  head ;  and  the  fontanelle  is, 
or  soon  becomes,  depressed.  The  face  and  body  generally  are 
pale,  and  the  complexion  sometimes  turns  yellowish,  assuming  a 
half-jaundiced  tint,  which  remains  several  hours,  or  even  days,  and 
then  disappears.     The  tongue  is  clean,  pink,  and  moist,  and  remains 


36  SIMPLE    ATROPHY. 

SO  as  long  as  there  are  no  symptoms  of  acute  digestive  disturbance. 
The  bowels  are  irregular  and  capricious ;  constipation  alternating 
with  occasional  attacks  of  diarrhoea.  The  common  condition  is 
constipation  ;  a  stool  occurring  every  second  day,  consisting  of 
hard,  whitish  lumps,  co'vered  with  a  stringy  mucus,  and  formed 
almost  entirely  of  undigested  food.  Its  evacuation  is  often  attended 
with  much  straining,  and  may  be  preceded  by  some  pain  in  the 
belly.  The  cause  of  this  sluggishness  of  the  bowels  is  the  presence 
of  mucus  secreted  in  unusual  quantities  on  account  of  the  irritation 
to  which  the  membrane  lining  the  alimentary  canal  is  exposed. 
This  mucus,  being  coagulated  by  the  acid  resulting  from  the  de- 
composition of  the  starchy  food,  covers  the  contents  of  the  bowels, 
and  also  forms  a  tenacious  lining  round  the  inner  surface  of  the 
intestine.  Consequently,  the  bowels  in  their  peristaltic  action, 
glide  over  the  slippery  surface  of  the  masses  of  food,  and  lose  their 
power  of  propelling  these  forwards  towards  the  outlet.  Sometimes, 
however,  instead  of  being  confined,  the  bowels  are  open  three  or 
four  times  a  day,  the  stools  being  green,  half-liquid,  slimy,  and 
extremely  offensive.  In  either  case  the  food  which  the  child  has 
taken  passes  through  him  without  being  digested. 

Flatulence  is  a  source  of  great  annoyance  to  the  infant.  It  may 
cause  paroxysms  of  violent  pain,  in  which  the  face  becomes  white, 
the  upper  lip  livid  and  everted,  and  the  belly  tense.  The  child 
utters  piercing  cries,  at  the  same  time  drawing  up  the  lower  limbs 
suddenly  and  violently  upon  the  abdomen.  Even  during  sleep 
frequent  startings  and  moanings,  elevation  of  the  corners  of  the 
mouth,  and,  if  the  pain  be  severe,  a  contraction  of  the  brows,  show 
that  the  child  is  suffering  from  abdominal  pains.  The  smile  which 
is  sometimes  seen  upon  the  child's  face  during  sleep  is  a  result 
of  the  same  cause,  although,  of  course,  to  a  much  less  degree. 
The  wind  is  often  evacuated  in  large  quantities,  or  comes  up  aS 
sour-smelling  eructations,  affording  great  relief.  The  temper  is 
exceedingly  irritable.  The  pain  and  uneasiness  from  which  these 
children  suffer,  and  which  is  constantly  being  renewed  by  every 
additional  meal,  makes  them  noisy  in  their  lamentations  to  a  degree 
which  is  almost  unbearable.  As  the  mothers  say,  "  they  wear  one's 
life  out."  At  night  this  is  especially  the  case.  At  that  time  they 
are  apt  to  be  feverish,  and  are  often  seized  with  fits  of  screaming 
which  nothing  will  appease,  and  which  sometimes  continue  until 
actual  exhaustion  compels  them  to  desist.     Even  then,  however, 


NETTLERASH  —  STROPHULUS  —  THRUSH.  37 

the  cries  are  renewed  at  intervals,  as  a  fresh  attack  of  abdominal 
pain  rouses  them  from  uneasy  sleep.  At  these  times  the  feet  are 
usually  cold,  although  the  belly,  hands,  and  cheeks  may  be  dry 
and  hot. 

But  in  spite  of  all  this,  or  rather  as  a  consequence  of  it,  the 
appetite  is  usually  enormous.  The  uneasiness  produced  by  acidity 
and  flatulence  will  often  excite  in  children  a  great  desire  for  food, 
and  unless  the  uneasiness  amount  to  actual  pain,  they  will  swallow 
ravenously  whatever  is  offered  to  them.  The  amount  of  farina- 
ceous matter  an  infant  will  consume  in  this  way  is  sometimes  very 
large,  and  the  fact  that,  in  spite  of  such  voracity,  the  child  should 
still  continue  to  waste,  excites  much  wonder  amongst  his  attend- 
ants. 

Attacks  of  nettlerash  and  strophulus,  either  separatel}''  or  com- 
bined, are  very  common.  With  the  appearance  of  nettlerash  every 
one  is  familiar.  Strophulus  may  be  either  of  the  red  or  the  white 
variety. 

Red  strophulus  (red  gum)  begins  in  a  red  blotch,  the  centre  of 
which  is  slightly  elevated.  The  redness  soon  fades,  and  the  cen- 
tral elevation  enlarges  and  forms  a  flattened  papule,  often  of  con- 
siderable size.  These  are  seated  on  the  face,  neck,  arms,  and 
sometimes  cover  the  whole  body. 

White  strophulus  appears  in  the  form  of  pearly  white  opaque.., 
papules,  smaller  than  the  preceding,  and  about  the  size  of  a  small 
pin's-head.     They  are  seen  usually  on  the  face  and  arms. 

The  presence  of  either  of  these  eruptions  (nettlerash  or  strophu- 
lus) on  the  body  of  a  young  child  is  a  certain  sign  of  digestive 
derangement. 

Thrush  (parasitic  stomatitis)  is  another  consequence  of  the  un- 
suitable diet  to  which  the  child  is  exposed,  and  is  especially  com- 
mon in  warm  weather.  The  mucous  membrane  of  the  mouth 
becomes  red;  then  little  concretions,  transparent  at  first,  afterwards 
pearly  white,  appear  on  the  reddened  surface,  unite,  and  form 
patches  varying  in  size,  and  looking  like  little  bits  of  curd  ad- 
hering to  the  tongue,  and  to  the  inside  of  the  cheeks  and  lips.  In 
very  bad  cases,  they  line  the  whole  interior  of  the  mouth,  and  may 
extend  into  the  fauces,  and  even  down  to  the  gullet.  According 
to  Trousseau,  they  are  not  developed  on  the  interior  of  the  sto- 
mach or  bowels,  being  limited  to  parts  of  the  mucous  membrane 
which  are   covered  with    scaly  epithelium.     At  the  same   time 


88  SIMPLE    ATROPHY. 

there  is  a  little  febrile  disturbance,  with  some  thirst ;  usually  vomit- 
ing ;  and  often  a  thin  watery  diarrhoea,  from  the  irritation  of 
deranged  intestinal  secretions.  If,  as  frequently  happens,  the  nates 
become  red  and  excoriated  by  the  discharges  from  the  bowels,  the 
thrush  is  said  by  nurses  to  have  "gone  through  "  the  child.  There 
is  some  tenderness  of  the  mouth,  and  if  the  child  be  put  to  the 
breast  in  the  course  of  this  complaint,  he  often  refuses  to  suck  on 
account  of  the  pain  excited  by  the  movements  of  the  tongue  and 
cheeks. 

The  concretions  are  due  to  a  cryptogamic  vegetation  (oidium 
albicans),  the  sporules  of  which  increase  with  great  rapidity,  and 
form  tubular  fibrils.  These,  with  an  increased  formation  of  epithe- 
lial scales,  constitute  the  white  patches  seen  on  the  mucous  mem- 
brane. The  plant  finds  a  nidus  in  the  altered  secretions  of  the 
mouth. 

This  is  either  a  mild  or  a  severe  complication,  according  to  the 
general  condition  of  the  child  in  whom  it  is  found.  If  it  occur  in 
a  child  who  has  been  reduced  to  a  state  of  great  weakness  by  a 
long  course  of  improper  food,  it  is  of  very  unfavorable  augury, 
for  in  such  a  case  our  hopes  of  improving  his  health  depend  upon 
the  rapidity  and  completeness  with  which  new  materials  for  nutri- 
tion can  be  introduced  into  his  system.  Anything,  therefore,  which 
tends  to  prevent  the  introduction  of  nourishment  tends  to  deprive 
the  child  of  this  his  only  means  of  recovery,  and  the  presence  of 
thrush  betrays  a  condition  of  the  digestive  passages  extremely  un- 
favorable to  the  ready  assimilation  of  food.  Besides,  the  diarrhoea 
which  is  so  apt  to  accompany  the  disorder,  especially  in  weakly 
children,  is  another  reason  for  regarding  the  occurrence  of  this 
complication,  in  such  cases,  with  considerable  anxiety. 

In  stronger  children,  want  of  cleanliness,  or  temporary  derange- 
ment set  up  by  improper  food,  may  give  rise  to  thrush,  but  here, 
if  the  strength  is  satisfactory,  recovery  is  usually  rapid ;  the  con- 
cretions become  grayer,  then  yellow  ;  fall  off,  and  are  not  renewed. 

Another  symptom  of  the  irritation  excited  by  unsuitable  food 
is  that  known  in  nurseries  under  the  name  of  "inward  fits."  The 
phenomena  which  constitute  the  condition  denoted  by  this  rather 
vague  expression,  are  ablueness,  or  lividity  of  the  upper  lip,  which 
is  rather  everted,  and  may  twitch;  a  slight  squint,  or  a  peculiar 
rotation  of  the  eye ;  with  contraction  of  the  fingers,  and  twisting 
inwards  of  the  thumbs.     These  symptoms  should  never  be  disre- 


APHTHA.  39 

garded,  as  they  are  often  the  precursors  of  an  attack  of  convul- 
sions. 

If  a  great  accumulation  of  food  has  taken  place  in  the  alimen- 
tary canal,  or  the  child  has  swallowed  some  substance  which  is 
more  than  usually  indigestible,  or  has  been  exposed  to  cold,  the 
symptoms  may  become  more  alarming.  The  skin  gets  very  hot, 
the  face  flushed,  and  there  is  violent  vomiting  of  sour-smelling 
food,  with  mucus,  preceded  by  great  retching.  The  efforts  to 
vomit  may  continue  after  the  stomach  has  been  emptied,  and  then 
green  or  yellow  bile  is  thrown  up.  At  the  same  time  the  bowels 
become  very  loose,  and  large  dark  green,  or  putty-like,  offensive 
motions  are  passed,  with  great  straining.  The  motions  often  con- 
tain little  lumps,  and  each  action  of  the  bowels  is  preceded  by 
much  griping,  during  which  the  child  screams,  draws  up  his  legs, 
and  throws  himself  uneasily  from  side  to  side.  The  tongue  is 
rather  dry,  and  is  thickly  coated,  white  or  yellow,  with  large, 
round,  red  or  pink  papillge  scattered  over  its  surface,  peering 
through  the  fur.  The  belly  is  full,  rather  hard,  and  irregular  to 
the  feel.  The  child  refuses  all  food,  but  is  very  thirsty  ;  he  usually, 
however,  vomits  the  fluid  he  has  taken  very  shortly  after  swallow- 
ing it.  Sometimes  a  convulsive  fit  ushers  in  this  attack,  and  may 
be  repeated  several  times.  Occasionally  these  fits  recur  in  such 
numbers,  and  with  such  violence,  as  to  cause  death  by  the  exhaus- 
tion they  induce.  The  vomiting  usually  ceases  after  the  first  day, 
or  is  repeated  at  longer  intervals,  but  the  diarrhcea  continues  two 
or  three  days,  unless  treatment  be  quickly  had  recourse  to,  and 
the  motions  change  their  character,  becoming  watery,  and  usually 
of  a  brown  color,  still  remaining  extremely  offensive.  If  the 
straining  be  great  there  may  be  slight  prolapse  of  the  bowels,  with 
a  little  blood  in  the  form  of  red  streaks  in  the  motions. 

In  children  over  twelve  months  old,  these  attacks  are  often  ac- 
companied by  aphthge  of  the  mouth.  They  are  found  on  the  tip 
of  the  tongue,  round  the  anterior  part  of  its  margin,  and  on  the 
inside  of  the  lower  lip.  They  consist  of  small  circular  superficial 
ulcers,  seated  at  the  follicles  of  the  mucous  membrane.  According 
to  MM.  Rilliet  and  Barthez,^  aphthiB  begin  as  vesicles,  the  epithe- 
lium of  the  follicle  being  raised  up  by  altered  secretion  in  its  inte- 
rior.    This  bursts,  and  a  small  ulcer  is  the  result.     At  the  same 

'  Maladies  des  Enfants,  tome  i.  8vo.,  Paris,  1861. 


40  SIMPLE    ATEOPHY. 

time  the  lower  gums  are  usually  red,  swollen,  and  shining;  they 
easily  bleed,  and  may  be  ulcerated  along  the  roots  of  the  incisor 
teeth.  There  is  also  increased  secretion  from  the  mucous  mem- 
brane of  the  mouth,  with  some  salivation.  The  number  of  the 
aphthae  varies  from  two  or  three  to  fifteen  or  even  twenty.  They 
are  very  rarely  solitary ;  usually  about  five  or  six. 

When  the  attack  subsides,  the  infant,  unless  a  better  system  of 
management  be  adopted,  goes  on  as  before,  the  wasting  continues, 
and  he  becomes  gradually  weaker  and  more  languid.  The  attacks 
of  acute  indigestion  recur  at  short  intervals,  each,  as  it  passes  off, 
leaving  him  more  prostrate,  and  less  able  to  withstand  the  injurious 
influences  which  are  gradually  wearing  away  his  life.  His  face 
becomes  wrinkled  and  old-looking;  his  eyes  dull  and  heavy;  his 
expression  languid,  or  peevish ;  and,  as  his  debility  increases,  the 
griping  pains  to  which  he  is  still  subject  excite  no  longer  a  fretful 
cry,  but  only  a  plaintive  moan,  or  merely  a  contraction  of  the 
features  without  any  sound.  His  emaciation  becomes  extreme ; 
his  belly  large ;  his  skin  harsh  and  dry ;  his  fontanelle  deeply  de- 
pressed ;  and,  finally,  some  secondary  disease  arises,  and  puts  an 
end  to  his  existence.  Any  acute  disease  attacking  a  child  in  such 
a  condition  is  almost  certainly  fatal,  for  all  resisting  power  has 
been  starved  out  of  him,  and  he  falls  a  ready  victim  to  a  disorder 
which,  in  a  healthy  child,  would  be  easily  manageable,  and  quickly 
cured.  The  least  catarrh  runs  on  to  bronchitis  or  lobular  pneu- 
monia ;  the  slightest  chill  may  set  up  an  uncontrollable  diarrhoea ; 
and  it  is  to  chronic  diarrhoea  that  the  final  cause  of  death  may  be 
most  usually  attributed — a  diarrhoea  which  may  last  weeks  or 
months,  and  there  is  matter  for  much  astonishment  in  the  length 
of  time  a  child  will  linger  on,  although  reduced  apparently  to 
nothing  but  skin  and  bone.  If  the  child  has  been  brought  up  en- 
tirely by  hand,  and  has  been  fed  improperly  from  his  very  birth, 
he  seldom  lives  longer  than  two  or  three  months.  If  he  has  been 
suckled  for  some  months  before  the  commencement  of  the  im- 
proper food,  he  has  greater  power  of  resistance;  and  although  un- 
der the  new  diet  he  will  soon  become  dull,  and  pale,  and  flabby, 
yet  the  eftects  upon  his  flesh  and  strength  are  less  noticeable,  and 
he  usually  drifts  into  rickets  before  any  appearances  have  been 
thought  sufficiently  serious  to  require  medical  interference. 

Treatment. — The  treatment  of  simple  wasting  from  insufficient 
nourishment  consists  principally  in  so  selecting  the  diet  of  the  in- 


MATERNAL    SUCKLING.         .  41 

fant,  with  due  regard  to  his  age  and  capabilities,  that  he  may  be 
able  to  digest,  and  therefore  to  be  nourished  bj  all  the  food  he 
takes.  To  do  this,  we  must  be  thoroughly  acquainted  with  the 
scale  of  diet  suited  to  a  healthy  child  from  his  birth  onwards ;  we 
are  then  able  to  vary  this  diet  according  to  the  digestive  power  we 
find  in  our  patient.  The  weaker  the  child,  the  more  nearly  does 
his  condition  resemble  that  of  a  new-born  infant  in  his  power  of 
assimilating  different  articles  of  food,  and  therefore,  the  earlier  in 
the  scale  must  we  look  for  the  nutriment  suited  to  his  wants. 

A  short  sketch  of  this  subject  will,  then,  not  be  out  of  place. 

The  child  ought,  if  possible,  to  be  suckled  by  his  mother. 
Most  mothers  are  able  to  perform  this  duty :  all  mothers  ought  to 
try ;  partly  for  their  own  sakes,  as  it  insures  uterine  contraction, 
and  prevents  mammary  abscesses ;  partly  for  the  child's  sake,  as 
the  milk  of  his  own  mother  is,  as  a  rule,  better  suited  to  him  than 
that  of  a  stranger.  In  cases  where  the  choice  lies  between  mater- 
nal suckling,  and  artificial  feeding,  the  mother  ought  to  do  every- 
thing in  her  power  to  avoid  the  latter  alternative.  "  Every  woman," 
says  StolV  "  who  can  bear  a  child,  can  suckle  it,  at  least  during 
the  time  she  keeps  her  bed  ;"  and  even  to  be  kept  to  the  breast  for 
this  short  time  is  an  advantage  to  the  infant  by  no  means  to  be 
despised.  If  the  mother  be  delicate  and  the  secretion  scanty,  good 
diet,  especially  stout,  will  often  cause  a  marked  increase  in  the 
secretion  of  milk.  On  the  other  hand,  if  she  have  been  over- 
stimulated  by  a  too  rich  diet,  diminishing  the  quantity  of  her  food, 
and  the  administration  of  a  gentle  saline  purgative,  generally  pro- 
duces a  plentiful  supply  of  milk.  Feverishness,  from  whatever 
cause,  will  necessarily  tend  to  diminish  the  lacteal  as  well  as  the 
other  secretions  of  the  body ;  in  such  cases,  therefore,  increasing 
the  quantity  of  food  would  have  an  effect  the  very  opposite  of  that 
which  it  is  desired  to  produce.  If  these  measures  fail,  the  breasts 
may  be  galvanized,  as  recommended  by  M.  Bouchut.^ 

Should  the  mother,  after  repeated  trials,  prove  unable  to  suckle, 
a  wet-nurse  must  be  provided.  In  choosing  a  nurse,  attention 
should  be  paid  to  two  points — viz.,  the  state  of  her  health,  and  the 
age  of  her  milk.  With  regard  to  her  health,  she  should  be  ex- 
amined  for   signs   of   phthisis,  scrofula,  or  syphilis;    her  breasts 

'  Prselectiones  in  diversos  Morbos  Chronicos.     Max  StoU.      Volumen  ii.  p.  115. 
2  Hygiene  de  la  premiere  Enfance.     Paris,  1862. 


42  ,  SIMPLE    ATROPHY. 

should  be  inspected,  and  we  should  endeavor  to  estimate  the  con- 
dition of  her  milk  from  its  appearance,  by  the  naked  eye  and  by 
the  microscope.  The  best  test,  however,  is  the  condition  of  her 
child,  who  should  always  be  examined.  If  he  is  healthy  and 
thriving,  the  milk  is  in  all  probability  in  a  satisfactory  state.  The 
age  of  the  milk  is  a  point  of  considerable  importance,  for  the 
farther  lactation  is  advanced,  the  more  casein  will  the  milk  con- 
tain, and  the  richer  will  be  its  quality.  It  is,  therefore,  advisable 
that  her  confinement  should  have  taken  place  at  about  the  same 
time  with  that  of  the  mother  whose  place  she  is  to  supply,  other- 
wise the  milk  may  be  unsuited  to  her  nursling.  It  is  often  neces- 
sary to  change  the  nurse,  for,  as  appears  from  the  investigation  of 
MM.  Vernois  and  Becquerel,  already  quoted,  in  the  milk  of  some 
women  the  quantity  of  the  oily  constituent  greatly  predominates. 
In  such  cases  the  milk  may  not  agree  with  the  child.  We  must 
not  rest  until  a  nurse  has  been  provided  w4io  is  in  every  way  fitted 
to  make  the  infant  strong  and  healthy. 

The  diet  of  the  nurse  should  be  liberal ;  a  certain  amount  of 
fresh  vegetables  and  fruit  should  be  included  in  her  meals,  and 
she  may  take  reasonable  quantities  of  wine  or  beer. 

Young  mothers  with  a  first  child  are  sometimes  awkward  in  the 
handling  of  their. charge,  and  this  is  not  unimportant.  Infants 
held  awkwardly  to  the  breast  often  find  a  difficulty  in  retaining 
the  nipple,  and  may  refuse  the  breast  and  be  very  fretful  on  this 
account.  The  mother  should  not  hold  herself  too  erect,  but  should 
bend  over  the  child  so  as  to  allow  the  nipple  to  fall  easily  into  his 
mouth.  The  child  should  be  placed  partly  on  his  side,  and  the 
mother  should  support  the  breast  with  the  two  first  fingers  of  her 
unoccupied  hand,  so  as  to  keep  it  steady  while  the  child  draws  the 
milk.  If  the  milk  flows  too  quickly  and  abundantly,  as  sometimes 
happens,  it  may  cause  vomiting  from  the  rapidity  with  which  it 
has  to  be  swallowed.  In  these  cases  she  should  be  taught  to  press 
gently  with  the  two  fingers  which  hold  the  breast,  so  as  to  regulate 
the  flow. 

The  new-born  infant  should  be  put  to  the  breast  a  few  hours 
after  birth  ;  or  as  soon  as  the  mother  has  recovered  from  the  first 
fatigues  of  labor.  This  course  has  several  advantages :  it  insures 
the  proper  contraction  of  the  uterus,  for  when  the  child  has  once 
taken  the  breast,  no  danger  from  after  hemorrhage  is  to  be  appre- 
hended :  the  child  has  the  benefit  of  the  thin,  watery  colostrum 


ADVANTAGES    OF    EARLY    SUCKLING.  43 

which  precedes  the  appearance  of  milk  in  the  breast,  and  which 
acts  as  a  gentle  laxative  upon  the  bowels,  clearing  out  the  meconium 
with  which  thej  are  loaded  ;  and  the  nipple  is  drawn  out  while  the 
breast  is  still  soft.  If  suckling  is  delayed  until  the  secretion  of 
milk  has  become  regularly  established,  the  breast  is  apt  to  be  dis- 
tended by  its  secretion,  so  as  almost  to  hide  the  nipple.  The  child 
has  then  great  difficulty  in  obtaining  a  hold  of  the  nipple,  and  may 
besides  suffer  much  pain  from  the  pressure  of  his  face  against  the 
hardened  gland.  No  food  of  any  kind  should  be  given  to  the  child 
at  this  time.  The  practice  of  giving  butter  and  sugar,  gruel,  &c., 
to  a  new-born  babe,  is  a  mere  cruelty,  and  must  be  strictly  forbid- 
den. The  child  should  be  put  to  the  breast,  as  Dr.  White^  has  ob- 
served, "  whether  there  be  signs  of  milk  or  not,"  and  there  is  more 
or  less  colostrum,  which  forms  a  sufficient  nourishment  until  the 
supply  of  milk  becomes  confirmed.  Whether  the  mother  is  after- 
wards to  suckle  her  child  or  not,  she  should  endeavor  at  any  rate 
to  do  so  for  the  first  month,  during  which  time  a  fitting  nurse  can 
be  secured,  if  a  wet  nurse  is  really  required. 

The  child  should  take  the  breast  at  regular  intervals,  every  two 
hours  during  the  day  for  the  first  six  weeks,  and  he  should  suck 
from  each  breast  alternately.  At  night  it  is  important  that  the 
mother  should  be  undisturbed ;  and  besides,  it  is  well  to  accustom 
the  child  to  quiet  during  the  hours  of  sleep.  He  should,  therefore, 
be  fed  for  the  last  time  at  11  P.  M.,  and  be  then  put  to  rest  in  a  cot 
in  the  nurse's  room,  until  five  o'clock  on  the  following  morning, 
when  he  may  again  take  the  breast.  By  this  means  the  mother  is 
insured  six  hours'  uninterrupted  sleep.  If,  during  the  interval,  he 
awakes  and  cries,  he  may  be  pacified  by  a  little  cow's  milk  and 
water;  but  it  is  wiser,  at  any  rate  after  the  first  few  weeks,  to  ac- 
custom him  to  take  nothing  between  the  hours  mentioned,  for  chil- 
dren, like  their  elders,  are  creatures  of  habit.  The  infant  soon 
becomes  used  to  the  plan,  and  will  wake  and  sleep  again  with  per- 
fect content  if  he  knows  that  his  cries  will  be  disregarded.  After 
six  weeks  the  interval  between  the  meals  should  be  increased  to  three 
hours  or  even  longer  if  the  child  shows  no  desire  for  the  breast. 
It  is  as  great  a  mistake  to  urge  an  infant  to  take  nourishment  as  it  is 
to  quiet  him  with  the  breast  whenever  he  cries.  The  mother  should 
be  able  to  perceive  when  her  child  cries  from  hunger,  and  when 

'  Treatise  on  the  Management  of  Pregnant  and  Lyiug-iu  Women.  By  diaries 
White,  M.D.     8vo.  2d  edit.,  1777. 


44  SIMPLE    ATROPHY. 

from  uneasines  or  ill-temper.  If  the  babe  rouses  himself  and  seems 
pleased  at  the  sight  of  the  mother,  clenching  his  hands,  and  flexing 
his  limbs,  he  is  hungry.  If  he  remains  passive,  he  does  not  require 
the  breast.  If  he  cries  peevishly,  has  a  hot  skin,  and  jerks  his 
lower  limbs  uneasily  about,  he  is  troubled  with  indigestion,  and 
the  milk  would  only  increase  his  discomfort. 

Up  to  the  age  of  six  months  the  breast  must  remain  the  child's 
sole  nourishment,  provided  that  the  secretion  of  milk,  and  its 
quality,  are  found  to  be  satisfactory.  If  not,  and  the  child  wastes, 
or  does  not  grow,  other  food  must  be  given  in  addition,  as  will  be 
afterwards  described. 

If  the  mother  cannot  suckle  her  infant,  and  a  wet-nurse  cannot 
be  provided,  the  child  must  be  "  brought  up  by  hand,"  feeding  from 
a  bottle.  Here  the  greatest  care  is  requisite.  The  substitute  for 
human  milk  should  resemble  that  fluid  as  closely  as  possible,  or 
by  proper  preparation  should  be  made  to  do  so.  The  milk  of  the 
ass  approximates  most  nearly  to  woman's  milk  in  the  proportion 
of  its  several  constituents,  and  forms  a  very  good  diet  for  infants, 
although,  sometimes,  it  is  found  to  have  a  slight  purgative  action 
upon  the  bowels.  If  this,  however,  cannot  be  procured,  cow's  milk 
is  the  one  to  which  recourse  is  usually  had,  and  this  has  at  any  rate 
the  advantage  of  being  always  obtainable.  Cow's  milk,  as  has 
already  been  stated  (see  page  33),  has  a  higher  specific  gravity,  and 
contains  more  casein,  but  less  sugar,  than  human  milk.  Dilution 
with  water,  and  the  addition  of  sugar,  will  readily  remove  these 
differences.  The  other,  and  greater,  objection  to  this  milk,  viz.,  the 
firm  clot  formed  by  its  casein  when  coagulated,  can  also  be  removed 
by  the  addition  of  an  alkali.  For  this  purpose  carbonate  of  potash, 
in  the  proportion  of  one  grain  to  each  ounce,  or  lime-water,  may 
be  used,  and  of  these  the  latter  is  usually  preferred.  Lime-water 
contains  half  a  grain  of  lime  to  each  fluidounce.  For  the  first  six 
weeks  the  milk  must  be  diluted  with  an  equal  quantity  of  lime- 
water,  and  must  be  sweetened  by  adding  a  teaspoonful  of  sugar  of 
milk^  to  each  six  ounces.    To  this  Sir  William  Jenuer^  recommends 

'  Sugar  of  milk,  or  lump  sugar  pounded,  should  always  be  used  for  children. 
The  ordinary  brown  sugars  contain  albuminous  matters,  which  decompose,  and 
set  up  a  kind  of  fermentation.  They  are  very  apt,  therefore,  to  disagree.  Sugar 
of  milk  also  usually  contaius  the  salts  of  the  milk,  which  are  not  without  their 
value  in  nutrition. 

"  Lectures  on  Rickets.  Medical  Times  and  Gazette,  May  12,  1860.  The  creaui 
is  also  useful  in  preventing  the  lime-water  from  causing  constipation. 


MODE    OF    PREPARING    COW's    MILK.  45 

the  addition  of  a  little  cream,  in  the  proportion  of  two  teaspoon- 
fuls  to  the  half  pint.  The  milk  must  not  be  boiled,  but  the  cold 
mixture  must  be  warmed  to  a  temperature  of  about  95°  Fahr.  by 
dipping  the  bottle  containing  it,  for  a  few  minutes,  into  hot  water. 
After  six  weeks  the  quantity  of  lime-water  may  be  diminished, 
one-third  part  being  added  to  two-thirds  of  the  milk ;  and  after 
three  months,  the  quantity  may  be  still  further  reduced  to  one- 
fourth.  After  four  or  five  months  the  cow's  milk  may  be  given 
pure.  During  all  this  time  the  quantity  of  sugar  of  milk,  and  of 
cream  added,  is  to  remain  the  same. 

The  child  must  be  fed  at  regular  intervals,  from  three  to  four 
ounces  being  given  every  two  hours  for  the  first  six  weeks.  The 
alkalinized  and  diluted  milk  should  be  put  into  a  feeding-bottle, 
and  the  child  allowed  to  suck  until  its  contents  are  exhausted.  If 
before  that  time  he  seems  satisfied,  he  should  never  be  pressed  to 
continue ;  the  first  show  of  indifference  is  a  sure  sign  that  he  has 
had  enough;  and  when  the  meal  is  concluded,  the  bottle  should 
be  at  once  removed.  It  is  injurious  for  infants  to  suck  at  an 
empty  vessel,  as  they  thereby  swallow  air,  which  is  afterwards  a 
cause  of  great  uneasiness.  If  any  milk  remains  in  the  bottle  at  the 
end  of  a  meal,  it  should  by  no  means  be  laid  aside  and  warmed 
for  a  subsequent  meal,  and  only  the  quantity  required  for  each 
particular  repast  should  be  prepared  at  one  time,  to  avoid  fermen- 
tation. 

The  kind  of  feeding-bottle  to  be  used  is  of  little  importance. 
Maw's  feeding-bottle,  and  the  "  Mamma"  bottle,  which  have  each  a 
mouth-piece  of  caoutchouc,  or  a  bottle  sold  by  Mr,  Elam,  of  Oxford 
Street,  in  which  the  mouth-piece  is  made  of  fine  cork,  can  all  be 
recommended.  It  is,  however,  of  extreme  importance,  that  the 
apparatus  should  be  kept  perfectly  clean.  Each  time  after  being 
used,  it  should  be  washed  out  with  water,  in  which  a  little  soda 
has  been  dissolved,  and  it  should  then  be  placed  in  a  basin  of  cold 
water  until  again  wanted.  It  is  best  to  have  two  bottles  which  can 
be  used  alternately. 

The  quantity  given  to  the  infant  must  be  carefully  regulated. 
For  the  first  two  or  three  weeks,  six  or  eight  tablespoonfuls  at  each 
meal  will  be  sufficient;  this  can  be  gradually  increased  as  the 
child  grows  older. 

When  the  child  is  six  months  old,  a  little  farinaceous  food  can 
be  given  without  danger,  and  will  be  indeed  a  useful  addition  to 


46  SIMPLE    ATROPHY. 

his  diet.  The  kind  of  farinaceous  food  to  be  chosen  is  of  consider- 
able importance,  and  in  the  selection  we  have  to  consider  not 
only  what  food  is  best  in  itself,  but  also  what  food  is  best  digested 
by  the  child.  The  same  food  will  not  agree  equally  well  with  dif- 
ferent infants,  and  in  cases  where  our  first  trial  is  unsatisfactory  it 
will  often  be  necessary  to  change  the  food  several  times  before  we 
have  found  the  one  which  is  suited  to  the  particular  case. 

The  farinte  contain  nitrogenous  matter,  starch,  and  salts  in  vary- 
ing proportions,  and  those  of  them  best  suited  as  food  for  infants 
which  approximate  most  nearly  to  milk,  the  natural  diet  of  the 
child,  in  the  relative  proportion  of  their  several  constituents.  Thus, 
the  relation  of  the  nitrogenous  or  nutritive  element  to  the  calori- 
fiant  is,  in  human  milk,  as  one  to  four ;  in'  wheaten  flour,  one  to 
five;  in  potatoes,  one  to  nine;  in  rice,  one  to  ten;  and  in  arrow- 
root, tapioca,  and  sago,  one  to  twenty.  The  calorifiant  matter 
exists  in  farinaceous  substances  in  the  form  of  starch,  which  during 
the  digestive  process  becomes  converted  into  sugar  before  being 
taken  up  by  the  absorbent  vessels.  But  that  this  change  should 
take  place,  it  is  important  that  by  proper  preparation  the  starch 
granules  should  be  brought  into  a  suitable  condition,  so  as  to  be 
readily  acted  on  by  the  digestive  organs. 

The  food  which  is  best  in  itself,  and  which  is  most  commonly 
found  to  agree,  is  wheaten  flour  prepared  in  the  following  way : 
a  pound  of  pure  wheaten  flour,  tied  up  very  tightly  in  a  pudding- 
cloth,  is  placed  in  a  saucepan  of  boiling  water,  and  is  allowed  to 
boil  constantly  for  ten  hours.  On  removing  the  cloth  at  the  end 
of  this  period,  a  yellowish-white  ball  is  seen,  feeling  softish  and 
rather  elastic  to  the  touch,  like  India-rubber.  When  cold,  the 
softer  outer  coating  is  cut  away,  and  the  hard  nucleus  which  is  left, 
is  reduced  to  powder  with  a  fine  grater.  This  powder,  exceed- 
ingly light  and  delicate,  is  of  a  pale  straw  color.  The  quantity  of  this 
farinaceous  food  to  be  given  is  of  extreme  importance.  An  excess 
of  this  diet  is  one  of  the  most  frequent  causes  of  the  acid  indiges- 
tion so  common  amongst  infants,  and  which  so  often  leads  to  the 
most  disastrous  consequences.  A  child  of  six  months  old  will 
seldom  be  found  to  digest  more  than  two  teaspoonfuls  of  this  food 
in  the  four-and-twenty  hours,  and  in  many  cases  half  that  quantity 
will  be  sound  sufiicient.  It  is  best  to  give  the  farinaceous  food 
twice  in  the  day.  For  each  of  these  meals  one  teaspoouful  of  the 
prepared  flour  is  rubbed  up  with  a  tablespoonful  of  cold  milk  into 


FARINACEOUS    FOOD.  47 

a  smooth  paste,  continuing  the  rubbing  until  all  lumps  have  disap- 
peared. A  second  tablespoonful  of  cold  milk  is  then  added,  and 
the  rubbing  is  repeated  until  the  mixture  has  the  appearance  of  a 
perfectly  smooth  cream,  A  quarter  of  a  pint  of  boiling  milk,  or 
milk  and  water,  is  then  poured  slowly  upon  the  mixture,  stirring 
briskly  all  the  time,  and  the  food  is  ready  for  use. 

If  the  boiled  flour  prepared  as  described  be  not  found  to  agree, 
a  smaller  quantity  should  be  given,  or  if  necessary  some  other 
farinaceous  food  should  be  tried.  Any  of  the  so-called  "  infant's 
food"  may  be  made  use  of,  and  sometimes  one,  sometimes  another, 
will  be  found  to  succeed ;  but  in  no  case  should  farinaceous  matter 
be  given  oftener  than  twice  in  the  day.  For  the  other  meals  sim- 
ple milk,  or  milk  and  lime-water,  should  be  used  as  before  directed. 

After  the  eighth  month,  a  little  thin  mutton  or  chicken  broth 
may  be  added,  all  grease  having  been  carefully  removed.  This 
must  be  given  as  an  independent  meal,  and  not  as  an  addition  to 
his  ordinary  meals. 

With  some  children,  in  spite  of  all  possible  precautions,  cow's 
milk  alone,  however  diluted  and  alkalinized,  causes  indigestion 
and  flatulence.  In  these  cases  it  is  necessary  to  make  some  addi- 
tion to  the  milk.  We  occasionally  find  that  young  infants  who 
vomit  the  cow's  milk  and  lime-water  sour  and  curdled  almost 
immediately  after  swallowing  it,  will  yet  bear  well  and  even  thrive 
upon  the  same  milk  prepared  with  a  small  quantity  of  farinaceous 
food.  The  action  of  the  farinaceous  matter  is  here  principally  a 
mechanical  one.  By  itself  it  probably  contributes  little  to  the 
nutrition  of  the  body,  but  when  thus  mixed  intimately  with  the 
,  milk,  it  separates  the  casein  into  minute  portions.  The  curd,  there- 
t  fore,  coagulates,  not  into  one  large  clot,  but  into  a  multitude  of 
small  clots,  which  are  more  readily  attacked  by  the  digestive  fluids. 
It  is,  however,  always  a  risk  to  give  farinaceous  food  to  very 
young  infants,  for,  before  the  secretion  of  saliva  has  become  esta- 
blished, there  is  alway  danger  lest  the  farinaceous  matter,  lying 
undigested  in  the  bowels,  should  ferment  and  give  rise  to  acid 
dyspepsia.  The  desired  object  may  be  as  readily  effected,  and 
without  danger  to  the  child,  by  adding  a  little  isinglass  or  common 
gelatine  to  the  diluted  milk.  One  teaspoonful  of  isinglass  dis- 
solved in  four  ounces  of  milk  and  water  will  prevent  the  running 
together  of  the  curd  while  it  is  itself  a  harmless  addition  to  the 


48  SIMPLE    ATROPHY. 

meal.  It  is  in  cases  such  as  these  that  "  Liebig's  food  for  infants,"^ 
is  so  valuable  a  resource.  This,  when  properly  prepared  with 
milk,  is,  so  far  as  the  author's  experience  goes,  always  well  digested 
even  by  the  youngest  infants,  who  thrive  upon  it  when  they  have 
been  unable  to  take  any  other  food. 

In  cases,  however,  where  milk-  alone  is  found  to  disagree,  we 
should  be  careful  to  satisfy  ourselves  that  it  is  really  the  milk 
which  is  at  fault,  and  not  its  method  of  preparation,  or  the  way  in 
which  it  is  given.  Too  large  a  quantity  may  have  been  given  at 
once,  or  the  meals  may  have  been  too  frequently  repeated,  or,  as 
so  constantly  happens,  the  whole  secret  may  lie  in  a  want  of  clean- 
liness of  the  feeding  apparatus.  Amongst  the  poorer  classes,  so 
common  is  this  fault,  that  it  is  really  the  exception  to  find  a  per- 
fectly clean  feeding-bottle,  and  a  large  proportion  of  the  deaths 
amongst  their  children  may  be  traced  to  this  carelessness  alone. 
Even  amongst  the  wealthier  classes,  in  cases  where  the  direction  of 
the  child's  meals  is  left  entirely  to  servants,  the  necessary  cleanli- 
ness is  not  so  common  as  could  be  wished.  The  first  care  of  a 
medical  man,  when  called  to  a  child  brought  up  by  hand,  should 
be  to  send  for  the  feeding-bottle,  and  to  satisfy  himself  by  sense 
of  smell  that  it  is  fit  for  use. 

The  above  description  of  the  method  of  bringing  up  a  child  by 
hand  is  also  applicable  to  cases  where  the  child  is  being  suckled 
on  impoverished  milk.  In  such  cases  the  breast  should  be  given 
only  twice  a  day,  his  feeding  at  other  times  being  conducted  accord- 
ing to  the  rules  laid  down.  A  useful  addition  to  the  breast-milk, 
where  an  addition  is  required,  during  the  first  few  weeks  of  life, 
is  a  mixture  of  cream  with  diluted  whey,  one  tablespoonful  of 
fresh  cream  is  added  to  two  of  whey,  and  the  mixture  is  diluted 
with  two  tablespoonfuls  of  hot  water.  This  may  be  given  from  a 
feeding-bottle  every  three  or  four  hours.  The  whey  should  be 
made  fresh  in  the  house,  as  required,  by  adding  prepared  rennet 
to  new  cow's  milk  in  the  proportion  of  a  teaspoonfal  to  the  pint 
of  milk,  after  which  the  curd  is  removed  by  straining  through 
muslin.  This  diet  must  not,  however,  be  continued  too  long. 
After  a  few  weeks  a  tablespoonful  of  milk  may  be  added,  and  this 
quantity  can  be  afterwards  gradually  increased. 

'  The  best  form  of  this  food  is  the  one  known  as  "Liebig's  patent  extract," 
prepared  by  Mr.  Mellin,  of  "  Liebig's  Concentrated  Patent  Milk  Company,"  16, 
Tichborne-ritreet,  Quadrant.     Full  directions  are  given  upon  the  bottles. 


WEANING.  49 

The  time  of  weaning  is  very  important.  Premature  weaning  is 
not  without  its  dangers,  but  when  deferred  too  long  it  is  a  fruitful 
source  of  evil.  In  ordinar}''  cases,  where  the  child  is  healthy,  and 
the  strength  of  the  mother  is  sufficient  for  the  task,  twelve  months 
should  be  allowed  to  elapse  before  the  child  is  weaned.  A  longer 
continuance  of  suckling  would  make  too  great  a  demand  upon  the 
strength  of  the  mother,  and  would  be  of  no  advantage  to  the  child, 
who  has  by  this  time  become  well  accustomed  to  other  food.  It  is 
sometimes  stated,  particularly  by  French  authors,  that  the  time  of 
weaning  should  be  regulated  by  the  progress  of  dentition  ;  that 
the  child  should  not  be  deprived  of  the  breast  until  the  period  has 
passed  during  which  the  accidents  attendant  upon  dentition  may 
be  expected — which  time  they  fix  at  the  evolution  of  the  canine 
teeth.  This,  however,  is  not  a  very  safe  guide,  as  rickets,  a  com- 
mon result  of  mal-nutrition,  may  postpone  indefinitely  the  evolution 
of  the  teeth.  In  these  cases,  to  continue  the  suckling  would  be  to 
encourage  the  very  evil  which  it  is  our  principal  object  to  prevent. 
The  existence  of  chronic  disease  in  an  infant  reared  entirely  by 
the  breast,  so  far  from  being  an  impediment  to  weaning,  is,  on  the 
contrary,  the  very  strongest  argument  in  favor  of  a  change  of  diet ; 
and  the  common  objection  of  mothers  that,  on  account  of  the  chikVs 
weakness,  they  "dare  not  wean  him,"  is  the  very  worst  objection 
that  could  be  possibly  urged,  and  is  a  sufficient  proof  that  the 
suckling  has  already  been  continued  far  too  long.  Human  milk 
is  the  best  food  for  infants,  not  on  account  of  any  specific  property 
it  possesses,  but  merely  because  it  is  the  most  digestible.  When, 
however,  it  is  so  poor  as  to  be  no  longer  nutritious,  it  ceases  to 
rank  as  food ;  and  by  pursuing  this  course,  we  fill  the  child's  sto- 
mach with  a  fluid  which  is  incapable  of  nourishing  him,  but  which, 
by  satisfying  his  appetite  for  the  nioment,  prevents  his  taking  a 
meal  which  would  be  really  beneficial. 

In  every  case  we  must  attend,  not  to  popular  prejudice,  but  to 
the  actual  condition  of  the  child.  Wasting,  in  a  non-syphilitic 
infant,  shows  the  necessity  for  some  change  in  the  diet.  But  this 
change  does  not,  unless  the  child  be  twelve  months  old,  consist 
necessarily  in  weaning,  His  condition  may  be  owing  to  a  too 
liberal,  or  to  a  too  scanty  supply  of  food,  and  we  must  make  him 
depend  more  upon  the  breast-milk,  or  less  upon  that  source  of 
nourishment,  according  as  to  which  of  these  two  causes  a  history 
of  his  previous  diet  leads  us  to  attribute  his  disease. 
4 


50  SIMPLE   .ATROPHY. 

In  giving  additional  food  to  children  at  tbe  breast,  a  difficulty 
often  arise  from  the  repugnance  of  the  child  himself  to  this  mode 
of  feeding.  Many  children,  particularly  those  who  have  been 
suckled  too  frequently,  and  to  whom  the  breast  has  been  offered 
as  a  means  of  quieting  their  cries,  greatly  prefer  this  way  of  taking- 
nourishment  to  any  other,  and  indeed  continually  refuse  it  in  any 
other  form.  In  these  cases,  should  the  mother's  milk  be  poor  in 
quality  (which  it  often  is,  although  very  abundant)  it  is  better,  if 
all  other  means  fail,  to  wean  the  child  suddenly,  as  this  offers  the 
only  plan  by  which  he  can  be  efficiently  nourished.  This  course, 
however,  should  only  be  resorted  to  when,  in  spite  of  great  perse- 
verance, Ave  have  not  succeeded  in  attaining  our  object.  A  little 
judicious  starvation  will  often  do  much. 

Although,  if  circumstances  will  allow  it,  the  child  should  be 
suckled  for  twelve  months,  yet  it  may  be  necessary  to  wean  him 
at  an  earlier  period,  thus  : — 

If  the  mother's  health  suffers  from  nursing. 

If  from  some 'cause,  as  pregnancy,  or  the  occurrence  of  acute 
disease,  her  milk  is  rendered  unwholesome  to  the  child. 

If  the  child  is  insufficiently  nourished  upon  the  breast-milk,  and 
yet  refuses  to  take  additional  food. 

In  all  these  cases  the  ordinary  time  of  weaning  must  be  antici- 
pated. 

A  moment  should  be  chosen  for  weaning  when  the  child  is 
not  feverish,  nor  suffering  pain  from  the  actual  cutting  of  a  tooth. 
It  is  best  to  wean  him  gradually,  lessening  by  degrees  the  number 
of  the  times  he  is  allowed  to  take  the  breast,  and  continuing  for 
about  a  week,  still  to  give  it  to  him  once  a  day;  after  which  this 
too  must  be  stopped.  If  the  child  has  been  fed  as  directed,  there 
is  very  little  difficulty  about  weaning;  he  may  be  fretful  for  a  few 
days,  and  even  refuse  his  food,  but  by  perseverance  he  becomes 
reconciled  to  his  loss. 

Children  sometimes  wean  themselves,  seeming  suddenly  to  take 
a  dislike  to  the  breast,  although  they  are  quite  healthy  and  are 
apparently  thriving  upon  the  milk.  This,  however,may  be  some- 
times occasioned  by  scantiness  of  the  milk.  Usually,  when  chil- 
dren refuse  the  breast,  some  cause  can  be  discovered  by  which 
the  process  of  sucking  is  rendered  difficult  or  painful.     Thus — 

Retraction  of  the  nipple  may  make  it  impossible  for  the  child 


CAUSES  OF  EEFUSAL  OF  BREAST.  51 

to  obtain  any  milk  until  the  nipple  has  been  drawn  out  by  a 
stronger  child,  by  a  cupping  glass,  or  by  the  mouth  of  the  nurse. 

Colic,  or  flatulence,  when  severe,  prevents  the  child  from  suck- 
ing until  the  pain  has  subsided.  In  milder  cases  of  abdominal 
discomfort,  infants  are,  however,  often  particularly  ravenous,  as  be- 
fore explained. 

Thrush,  or  aphthae  of  the  mouth,  may  have  the  same  effect- 
Here  the  pain  caused  by  the  movements  of  the  mouth  during  the 
act  of  sucking  is  the  reason  of  the  refusal. 

Closure  of  the  nares  from  syphilitic  swelling  and  incrustation, 
or  from  measles,  obliges  the  child  to  breathe  entirely  through  the 
mouth.  Here,  whenever  he  attempts  to  take  the  breast,  a  sense  of 
suffocation  compels  him  to  abandon  the  nipple. 

In  bronchitis,  pneumonia,  and  broncho-pneumonia,  the  child 
sometimes  refuses  the  breast ;  for  there  is  laborious  respiration,  and 
both  nose  and  mouth  are  wanted  for  air-passages. 

In  tongue-tie^  and  cleft  palate,  there  is  a  mechanical  obstacle  to 
sucking,  in  the  impossibility  of  producing  the  necessary  vacuum 
in  the  mouth.  The  former  is  readily  cured  by  snipping  the  freenum. 
The  latter  necessitates  artificial  feeding;  but  by  an  ingenious  and 
simple  contrivance,  designed  by  Mr.  Oakley  Coles,  the  impediment 
to  sucking  from  a  feeding-bottle  can  be  overcome,  although  the 
child  is  still  prevented  from  taking  the  breast.  The  plan  consists 
in  attaching  to  the  nipple  of  Maw's  feeder  a  flap  of  elastic  India- 
rubber,  cut  to  fit  the  roof  of  the  mouth.  This  flap,  shaped  like 
the  bowl  of  a  teaspoon,  is  cut  out  of  the  sheet  elastic,  and  is  sewn 
to  the  upper  part  of  the  stalk  of  the  nipple  where  this  projects 
from  the  shield.  In  the  mouth  of  the  infant  the  flap  forms  an  ar- 
tificial palate,  against  which  the  nipple  is  pressed  during  suction, 
and  the  fluid  is  thus  prevented  from  passing  into  the  nose  in  the 
act  of  swallowing. 

"When  the  child  has  become  accustomed  to  do  without  the  breast- 
milk,  he  may  begin  to  take  the  food  which  is  hereafter  to  form  his 
ordinary  diet.  Potatoes  carefully  mashed  with  a  spoon,  with  gravy  ; 
light  puddings;  eggs  very  lightly  boiled  ;  or  a  bone  to  suck,  may 
be  allowed.     No  meat,  however,  should  be  given  till  the  sixteenth 

1  By  "  tongue-tie"  is  here  meant  those  cases  where  the  frsenum  is  attached  to 
the  whole  under  surface  of  the  tongue  as  far  as  the  tip.  Such  cases  are  exceed- 
ingly rare.  The  ordinary  cases  of  so-called  tongue-tie  present  no  real  obstacle  to 
sucking,  and  need  not  be  interfered  witli. 


52  SIMPLE    ATROPHY. 

or  eighteenth  month,  when  he  may  begin  with  a  very  small  quan- 
tity once  in  the  day.  The  best  kind  is  a  small  piece  of  roast  mut- 
ton, without  any  fat  or  grease.  This  should  be  very  finely  minced, 
or  even  pounded  in  a  mortar  to  insure  fine  division,  for  a  young 
child  will  not  chew  his  food.  With  this  he  may  drink  plain  water, 
toast-water,  or  milk-and-water. 

For  further  and  more  complete  information  on  the  subject  of 
feeding  children,  see  Chap.  XL,  Diets  1  to  11. 

In  making  the  different  changes  in  the  diet,  it  is  important  to 
watch  the  child  carefully,  so  that  too  great  precipitancy  may  be 
avoided.  Any  signs  of  labored  digestion  should  be  carefully 
noted,  and  a  simpler  diet  at  once  returned  to.  The  child  when 
awake  should  be  active  and  cheerful,  and  his  sleep  should  be  tran- 
quil and  undisturbed. 

While  attention  is  thus  paid  to  diet,  all  the  other  precautions, 
indispensable  to  perfect  health  should  be  observed. 

The  greatest  cleanliness  must  be  maintained.  Every  morning 
the  whole  body  should  be  well  washed  with  soap  and  warm  water, 
and  should  be  bathed  every  evening  with  tepid  water  before  he  is 
put  to  bed.  After  each  bath  the  body  and  limbs  should  be  gently 
rubbed  with  the  hand.  The  younger  the  child  the  warmer  should 
be  the  water  employed.  At  first  the  temperature  should  be  about 
90°  Fahr.,  but  after  a  few  months  it  may  be  gradually  used  cooler, 
although  it  should  never  be  lower  than  60°  Fahr.  Soap  is  re- 
quired thoroughly  to  remove  the  tenacious  cutaneous  secretions  and 
the  dirt.  The  use  of  soap  is  said  by  some  writers  to  make  the  skin 
too  dry,  and  subject  to  cracks,  but  if  frictions  are  used  after  each 
bath,  this  objection  is  removed,  as  the  skin  is  thus  excited  gently 
to  act,  and  remains  sufficiently  lubricated.  His  napkin  should  be 
changed  sufiiciently  often,  and  the  nates  after  each  action  of  the 
bowels  should  be  well  sponged  with  warm  water,  and  carefully 
dried.  He  should  sleep  by  himself  in  a  little  cot,  without  curtains  ; 
not  in  the  same  bed  with  his  nurse.  The  nurseries  should  be  large 
and  well  ventilated,  but  not  too  hot,  especially  at  night.  They 
should  face  the  south,  if  possible,  as  sunlight  is  of  great  import- 
ance. He  should  be  taken  out  frequently  into  the  air,  whenever 
the  weather  permits.  His  out-door  dress  should  be  warm,  and  as 
a  further  protection  against  the  cold,  he  should  wear  a  flannel  ban- 
dage round  the  belly. 


CONSTIPATION.  63 

From  the  sketch  given  in  the  preceding  pages  of  the  scale  of 
diet  suited  to  a  healthy  child,  it  is  easy  so  to  arrange  the  number 
and  quality  of  his  meals  that  a  sufficient  amount  of  nourishment 
may  be  given  without  overtasking  his  digestive  powers.  When 
the  diet  has  been  properly  regulated,  the  child  is  found  rapidly  to 
regain  flesh,  his  peevishness  and  irritability  disappear,  and  his  health 
returns.  Any  digestive  derangement  which  may  occur  should  be 
at  once  attended  to,  and  as  this  is  usually  due  to  some  deviation 
from  the  prescribed  rules,  a  return  to  the  proper  diet  will  generally 
cause  it  quickly  to  disappear,  especially  if  a  gentle  laxative  be 
given  at  the  same  time.  The  constipation,  Avhich  is  so  common  a 
result  of  the  improper  food,  often  continues  after  the  change  of 
diet.  In  these  cases,  if  the  child  be  at  the  breast,  the  mother  should 
take  an  occasional  saline  aperient,  and  should  increase  the  quantity 
of  fresh  vegetables  to  her  meals.  Should  this  plan  be  insufficient, 
a  teaspoonful  of  castor  oil  may  be  given  to  the  child ;  or  a  few 
grains  of  magnesia  with  syrup  of  ginger,  in  some  aromatic  water, 
may  be  administered;  or  a  little  manna  in  a  teaspoonful  of  infu- 
sion of  senna.  If,  after  repeated  attempts,  we  find  that  a  daily  ac- 
tion of  the  bowels  cannot  be  obtained,  without  a  daily  repetition 
of  the  aperient,  the  constipated  condition  of  the  bowels  may  be 
natural  to  the  child.  We  should,  therefore,  wait  to  see  if  his  health 
or  temper  suffers  from  his  costive  habit.  Should  we  find  that 
acidity,  with  flatulence  or  colic,  results  from  constipation,  we  must 
continue  our  efforts  to  remove  this  tendency.  When  it  is  thus 
necessary  to  continue  the  laxative  from  day  to  day.  Dr.  Underwood^ 
recommends  a  cold  infusion  of  senna  to  be  combined  with  some 
bitter  tonic,  as  the  infus.  gentianse  co.  This  may  be  given  in  in- 
creasing doses  until  the  torpor  of  the  bowels  is  overcome;  or  a 
small  piece  of  castile  soap,  introduced  as  a  suppository,  will  have 
the  same  effect. 

Daily  frictions  over  the  belly  with  the  hand,  or  with  some  stim- 
ulating liniment,  are  also  very  useful  in  promoting  a  daily  evacua- 
tion.   Dr.  Merriman^  sug-srests  the  addition  of  aloes  to  the  liniment : — 


"03^ 


I^.  Tinct.  aloes  co.,  ,^ss  ; 

Liuim.  saponis  co.,  §j.     M.  ft.  linimentum. 

'  Treatise  on  the  Diseases  of  Cliildren.    Edited,  with  additions,  by  Henry  Davies, 
M.D.     London,  1846,  tenth  edition. 
2  Underwood,  p   192. 


54  SIMPLE    ATROPHY. 

This  should  be  rubbed  into  the  belly  every  morning.  If  the 
child  is  twelve  months  old,  aloes  given  by  the  mouth  is  warmly 
advocated  by  Dr.  Dunglison.^  A  drachm  of  the  powdered  soco- 
trine  aloes  should  be  dissolved  in  an  ounce  of  simple  syrup;  of 
this  one  teaspoonful  may  be  given,  and  may  be  repeated,  if  neces- 
sary, until  a  satisfactory  stool  is  obtained. 

In  cases  where  the  constipation  is  very  obstinate,  where  hard 
clay-colored  motions,  often  mottled  with  streaks  of  green,  are 
passed  at  rare  intervals,  with  violent  expulsive  efforts  giving  rise 
to  much  suffering,  Dr.  Ringer  recommends  one  or  more  drops  of  a 
solution  containing  one  grain  of  podophylline  in  a  drachm  of 
alcohol,  to  be  given  to  the  infant  on  a  lump  of  sugar  two  or  three 
times  in  the  day.  This  treatment  restores  the  natural  color  to  the 
motions,  removes  the  abnormal  distension,  and  eases  the  colic. 

Enemata  are  often  very  serviceable,  administered  either  alone, 
or  as  an  aid  to  the  action  of  purgatives  taken  by  the  mouth.  Two 
or  three  drachms  of  castor  oil,  with  four  ounces  of  thin,  warm 
gruel,  may  be  used  for  a  child  of  twelve  months  old ;  or  ten  to 
twenty  grains  of  socotrine  aloes  dissolved  in  four  ounces  of  boiled 
milk,  may  be  administered  to  a  child  of  the  same  age.  In  using 
these  injections,  the  tube  must  be  well  oiled,  and  must  be  very 
carefully  introduced,  remembering  that  the  bowel  inclines  gradu- 
ally to  the  left  side.  The  fluid  should  be  thrown  up  with  moderate 
force. 

In  children  who  suffer  from  habitual  constipation,  care  should 
be  taken  to  keep  the  feet  perfectly  warm.  A  warm  bath  will 
often  produce  an  action  of  the  bowels  when  aperients  have  been 
given  without  any  effect. 

Rhubarb  should  not  be  used  as  a  purgative  in  children  where 
the  constipation  is  obstinate,  unless  combined  with  jalap  or  scam- 
mony,  or  some  other  purgative,  on  account  of  its  after  astringent 
effects ;  but  for  the  same  reason  it  is  extremely  valuable  in  the 
looseness  of  the  bowels  which  is  the  result  of  acidity.  Acidity  is 
produced  by  fermentation  of  the  food  in  the  alimentary  canal,  and 
gives  rise  to  much  flatulence,  shown  by  sour-smelling  eructations 
and  griping  pains  in  the  belly.  In  these  cases  the  feeding  appa- 
ratus should  always  be  examined,     A  want  of  cleanliness  in  the 

'■  Commentaries  on  Diseases  of  the  Stomach  and  Bowels  of  Children.  By 
Robley  Duuglison,  M.D.     Loudon,  182'4. 


CASE    ILLUSTRATING    SIMPLE    ATROPHY.  55 

bottle  is  a  common  cause  of  this  teasing  derangement.  If  the 
griping  is  accompanied  by  constipation,  the  bowels  should  be 
opened  by  a  gentle  purge,  as  magnesia  and  senna,  or  castor  oil, 
after  which  the  following  mixture  may  be  ordered : — 

I^.  Sodse  bicarb.  5j  » 
Sp.  chloroformi, 
Tiuct.  myrrlige,  aa  Jss  ; 
Aq.  menth.  pip.  ad  |ij. 

M.     3J  sextS,  quaque  hora. 

Aromatics  are  very  useful  in  these  cases,  and  indeed  should 
always  be  included  in  mixtures  for  children  wherever  there  are 
any  signs  of  intestinal  irritation. 

The  following  case  well  illustrates  the  value  of  alkalies  and 
aromatics  conjoined  with  a  regulated  diet,  in  the  treatment  of 
simple  atrophy  accompanied  by  constipation  and  flatulence. 

George  M.,  aged  two  months,  has  been  pining  away  ever  since 
birth.  "Is  not  half  the  size  he  was."  Does  not  cry  loudly  but 
"  frets  and  pines."  Is  suckled,  but  the  mother  has  very  little  milk ; 
is  therefore  fed  besides  on  sago  and  corn  flour  made  with  water. 

Child  is  bright-looking,  but  very  small  and  thin.  Fontanelle 
depressed.  Lips  rather  pale.  Nasal  furrow  not  marked.  Tongue 
clean,  color  of  rust  of  iron.  Skin  cool,  not  rough  or  harsh  :  a  little 
eczema  about  folds  of  groin.  Anus  a  little  red,  but  no  cracks  or 
fissures  there.  Does  not  snuffle.  Is  not  sick.  Bowels  act  once 
or  twice  a  day.  Motions  in  little  light-colored  lumps  with  mucus, 
not  offensive,  passed  with  some  straining.  Moves  legs  uneasily,  as 
if  griped. 

Was  ordered  to  be  fed  on  milk  and  lime-water,  in  equal  propor- 
tions, given  every  three  hours.  No  other  food  except  breast-milk. 
A  flannel  bandage  to  be  applied  round  the  belly.  A  teaspoonful 
of  the  following  mixture  to  be  given  three  times  a  day : — 

5.  Sod?e  bicarb,  gij ; 
Syrupi  zingib., 
Aq.  menthae  piper.,  aa  ^ss. 
Aquam  ad  §iij.     M. 

At  the  next  visit  a  week  afterwards : — Continues  to  waste. 
Sometimes  refuses  the  bottle  and  the  breast,  apparently  from  the 
pains  in  belly.  Belly  very  hard;  child  wrinkles  forehead,  draws 
up  the  corners  of  his  lips,  and  flexes  thighs  on  to  abdomen. 
Bowels  open  twice  a  day  with  straining.     Motions  light-colored, 


56  SIMPLE    ATROTHY. 

solid,  aud  smell  sour ;  no  mucus.  Feet  examined  and  found  to 
be  very  cold.     Tongue  clean. 

Feet  to  be  kept  warm  by  friction  with  the  band.  The  milk  and 
lime-water  to  be  continued. 

I^.   Pulv.  rlifei, 

Sodse  Lic/irb.  aa  gr.  iij.     Ft.  pulv.  statim.  sumend. 

I^.  Bismutlii  subuitratis,  9j  ; 
,  Pulv.  cretse  aromat.,  gss  ; 

Syrupi, 
Mucilaginis,  aa  .^iss.     Ft.  mist,  jij  ter  die. 

On  the  following  week : — Child  very  much  better ;  is  beginning 
to  gain  flesh.  Motions  still  light  colored  and  rather  firm  ;  two  in 
the  day.  Still  rather  flatulent;  turns  "deadly  white"  at  times 
(when  violentl}''  griped). 

To  continue  the  same  diet.  Half  a  drop  of  tinct.  capsici  added 
to  each  dose  of  the  mixture. 

After  this  the  flatulence  ceased ;  the  motions  became  natural ; 
and  the  child  rapidly  became  fat  and  well. 

If  the  bowels,  instead  of  being  confined,  are  rather  loose,  with 
dark,  slimy,  offensive  stools,  a  dose  of  powdered  rhubarb  and  mag- 
nesia, five  grains  of  each,  should  be  given,  and  may  be  followed  by 
the  above  mixture,  with  the  addition  of  half  a  drop  of  laudanum 
to  each  dose  ;  or  the  following^  may  be  given  : — 

^.  Tinct.  opii,  iH^xij  ; 
01.  ricini,  3j  ; 
Syrupi  zingib.,  ^ss  ; 
Mucilag.  acacise,  ad  §ij.     M.     3j  ter  die. 

If  there  is  a  sour  smell  from  the  breath,  a  few  grains  of  prepared 
chalk  may  be  substituted  in  each  dose  for  the  castor  oil.  At  the 
same  time  all  farinaceous  foods  should  be  suspended  for  a  day  or 
two,  and  the  diet  be  limited  to  milk  and  lime-water,  or  plain  milk. 
In  all  these  cases  of  abdominal  pain,  the  feet  should  be  examined, 
for  cold  feet  alone  may  be  the  cause  of  the  griping ;  should  such 
be  the  case,  on  warming  them  the  manifestations  of  pain  will 
cease. 

If  a  return  to  the  ordinary  diet  is  followed  by  the  same  flatulent 
condition,  and  this  happens  several  times  in  succession,  the  food 

'  In  the  screaming  fits,  accompanied  by  constipation,  this  combination  of  cas- 
tor oil  with  laudanum  is  exceedingly  valuable. 


FLATULENCE    AND    COLIC.  57 

evidently  does  not  agree  with  the  child,  and  some  alteration  is 
required.  Trials  should  be  made  of  different  kinds  of  foods,  for, 
as  already  explained,  the  same  food  is  not  suited  to  every  case. 
Liebig's  food  is  a  great  resource  under  such  circumstances.  Some- 
times  it  is  the  milk  which  disagrees,  and  we  are  forced  to  discon- 
tinue it  altogether,  giving  instead  beef,  veal,  or  mutton  broth, 
thickened  with  some  farinaceous  food.^  When  the  flatulence  is 
thus  obstinate,  frictions  with  a  stimulating  liniment  should  be  em- 
ployed daily  to  the  belly,  the  flannel  bandage  being  removed  for 
the  purpose,  and  afterwards  replaced.  A.t  the  same  time  a  mix- 
ture containing  infusion  of  rhubarb,  with  a  little  tincture  of  myrrh, 
may  be  given  twice  or  three  times  in  the  day,  to  give  tone  to  the 
bowels,  and  increase  their  peristaltic  action : — 

^.  Infusi  rhsei,  §j  ; 

Syrupi  zingib.,  ^ss  ; 
Tiuct.  myrrlije,  5s3  ; 
Aq.  meiith.  pip.  ad  §iij.     M. 
gij  bis  vel  ter  die. 

If  sickness  accompanies  the  flatulence,  a  teaspoonful  of  ipecacu- 
anha wine  should  be  given  to  relieve  the  stomach ;  after  which  a 
mixture  containing  bismuth  and  magnesia  may  be  ordered : — 

I^.    Bismutlii  subnitratis,  5==^  ; 
Magnesise  carb.,  ^ij  ; 
Syrupi  zingib.,  ^ss  ; 
Mncilag.    tragacanth.  §ss  ; 
Aquamad3ij.     M.     3J  ^^^  ^^'^' 

Or  the  mixture  containing  bicarbonate  of  soda  with  spirits  of  chlo- 
roform and  tincture  of  myrrh  (see  p.  55)  may  be  used. 

When  the  colic  is  very  severe,  great  alarm  may  be  excited  by 
the  state  of  apparent  collapse  into  which  the  infant  is  thrown.  The 
child  should  be  placed  in  a  warm  bath ;  the  bowels  should  be  re- 
lieved by  an  injection  of  warm  water;  and  a  few  drops  of  brandy 
or  sal  volatile  should  be  given  in  milk  or  water.  On  being  re- 
moved from  the  bath,  the  child  must  be  carefully  dried ;  a  hot  lin- 
seed meal  poultice,  on  which  ten  or  fifteen  drops  of  laudanum  have 
been  sprinkled,  should  be  applied  to  the  belly ;  and  he  should  be 
then  wrapped  up  in  warm  flannel.  If  the  fontanelle  remain  depressed, 
the  brandy  may  be  repeated,  and  a  mixture  containing  sal  volatile 
with  spirits  of  chloroform  and  a  little  bicarbonate  of  soda  may  be 
prescribed : — 

'  See  also  Diets  12  aud  13,  Chap.  XL 


58  SIMPLE    ATROPHY. 

^  .    Sodse  bicarb.,  ^ij  ; 
Sp.  chloroformi,  gss ; 
Sp.  amnion,  aromat.,  ^ss  ; 
Aq.  anethi  ad  5ij.     M.     ^ij  tertia  quS,qiie  bora. 

Convulsions  may  arise  from  this  condition  of  the  bowels,  and 
must  be  treated  in  the  same  way.  If,  however,  they  continue,  and 
are  not  relieved  by  the  measures  adopted,  Dr.  Graves^  recom- 
mends turpentine  to  be  given  : — 

I^.    01.  terebintbinse,  3j  ; 
01.  ricini,  giv  ; 
Mist,  acacise, 
Aq.  cinnamomi,  aa  §iij.     M.     5j  tertiS.  quaque  horS,. 

This  acts  on  the  bowels  and  produces  a  copious  discharge  of  urine. 
On  recovery,  great  attention  should  be  paid  to  the  diet  and  bowels, 
that  the  symptons  may  not  return. 

Thrush  is  readily  cured  by  attention  to  cleanliness.  It  should 
be  made  a  rule  always  to  wash  out  the  child's  mouth  immediately 
after  a  meal,  to  prevent  any  accumulation  of  food  or  milk  round 
the  gums.  This  is  readily  done  with  a  good-sized  camel's  hair 
brush,  or  a  piece  of  linen  rag  dipped  into  warm  water.  Attention 
to  this  point  will  prevent  the  appearance  of  thrush,  especially  if 
care  be  taken  that  the  nipple  of  the  mother  is  perfectly  clean. 
When  thrush  has  appeared,  the  bowels  should  be  cleared  out  with 
a  gentle  aperient,  and  the  mouth,  after  being  cleansed  with  warm 
water,  should  be  brushed  over  with  a  solution  of  borax  in  glyce- 
rine (half  a  drachm  to  the  ounce),  or  with  a  solution  of  hyposul- 
phite of  soda.     By  these  means  the  parasite  is  readily  destroyed. 

If  aphtha  form,  the  same  attention  should  be  paid  to  cleanliness  ; 
a  powder  of  rhubarb  and  jalap,  with  a  grain  of  hydrargyrum  cum 
creta  should  be  given  to  evacuate  the  bowels ;  after  which  the  fol- 
lowing mixture  should  be  prescribed: — 

R.    Potas.  chloratis,  9ij  ; 
Syrupi  simpl.  5ss  ; 
Aquam  ad  5iij.     M.     ^ij  quarta  quaque  bora. 

This  must  not  be  diluted,  as  it  is  important  that  the  solution  of 
chlorate  of  potash  should  be  tolerably  strong.  When  attacks  of 
acute  indigestion  come  on,  with  hot  skin,  furred  tongue,  thirst, 
vomiting,  and  diarrhoea,  accompanied  by  griping  pain,  all  food 
must  be  stopped,  and  nothing  be  allowed  but  cold  barley-water. 

'  Graves'  Clinical  Medicine.     Edited  by  Dr.  Neligan. 


ACUTE    INDIGESTION.  59 

The  stomach  should  be  relieved  by  an  emetic  of  ipecacuanha,  after 
the  action  of  which  a  purgative  of  rhubarb  and  magnesia  should 
be  given  to  clear  out  irritating  matters  from  the  bowels.  A  mix- 
ture of  chalk  and  catechu  with  aromatic  confection  can  then  be 
given;  or  the  following: — 

IJl.    Bismuthi  subnitratis,  9j  ; 
Fnlv.  cretse  aromat.,  3j  ; 
Syvnpi,  3SS  ; 

Mueilag.  tragacanth.,  §ss  ; 
Aquam  ad  §iij.     M.     gij  ter  die. 

If  the  diarrhoea  continues  after  the  toiigue  has  become  clean,  half 
a  drop  of  laudanum  can  be  added  to  each  dose  of  either  of  these 
mixtures,  or  small  doses  of  sulphuric  acid  may  be  given  with 
opium: — 

^.    Acidi  sulphurici  aromat.,  jSS  ; 
Tinct.  opii,  iTj^vj  ; 
Syrupi,  gss  ; 
Aqiaam  carui,  ad  §iij.     M.     5'j  ter  die. 

When  the  irritability  of  the  stomach  has  subsided,  milk  and  lime- 
water  may  be  given,  but  with  caution,  lest  the  vomiting  return ; 
and,  after  subsidence  of  the  fever,  great  prudence  should  be  exer- 
cised in  recommencing  the  ordinary  diet. 


CHAPTEE    II. 

CHRONIC    DIARRHCEA, 

Chronic  Biarrhcea. — May  be  secondary  to  acute  disease — Or  primary — When 
primary — Mode  of  commencement — Increased  peristaltic  action  of  bowels — 
When  disease  established — Character  of  the  stools — Other  symptoms — 
Complications — Serous  elFusions — Pneumonia — Exanthemata — Convulsions, 
uncommon,  except  towards  beginning — Thrombosis  of  cerebral  sinuses — 
Death  without  complication — Diarrhoea  may  cease  before  death — Influence  of 
the  disease  upon  dentition. 

Causes. — In  infants — Bad  hygiene — Cold — Previous  acute  disease — In  older  chil- 
dren— Worms — Tubercular  disease  of  bowels. 

Anatomical  Characters. — Non-tubercular — Tubercular. 

Diagnosis. — Between  simple  and  tuberculous  form. 

Pro(/nosis. — Signs — Favorable — Unfavorable. 

Prevention. — Attention  to  diet — Avoidance  of  cold — Influence  of  dentition. 

Treatment. — Diet  and  general  management — External  applications — Internal 
remedies — Antacids — Astringents — Enemata — Opium— Nitrate  of  silvei* — 
Raw-meat  plan — Tonics. 

Chronic  Diarrhoea  may  either  occur  as  the  sequel  of  an  acute 
attack,  or  may  begin  insidiously. 

In  the  former  case  it  is  often  secondary  to  some  acute  disease, 
as  measles  or  scarlatina.  Here  there  is,  in  addition  to  the  diarrhoea, 
fever,  though  perhaps  of  slight  intensity,  abdominal  pains,  languor, 
loss  of  appetite,  and,  very  frequently,  vomiting.  This  attack  may 
subside  for  a  time,  but  recurs  again  and  again,  until  the  chronic 
disease  becomes  established. 

When  chronic  from  the  first,  fever  is  absent.  The  stools  are 
not  very  frequent,  usually  three  or  four  in  the  day.  They  are 
pale,  often  of  the  color  and  consistence  of  putty,  and  are  evacuated 
with  much  straining  and  pain.  At  this  stage  the  disease  seems  to 
consist  merely  in  increased  peristaltic  action  of  the  intestines 
forcing  along  their  contents  too  rapidly  to  allow  of  efficient  diges- 
tion being  performed.  The  motions  consist  of  curds  and  farina- 
ceous matter,  from  the  milk  and  food  which  has  been  swallowed, 
mixed  with  some  half-liquid  feces,  and,  if  there  be  much  straining, 


CHARACTER    OF    THE    STOOLS.  61 

with  mucous  and  blood.  The  blood  at  this  time  is  iu  the  form  of 
red  streaks,  and  results  from  the  rupture  of  small  vessels  about  the 
anus  in  the  act  of  straining.  In  such  a  form  it  is  a  common 
accompaniment  of  diarrhoea  in  children  where  there  is  much  te- 
nesmus. The  stools  have  often  an  offensive  sour  smell.  The  child 
looks  rather  dull  and  pale,  but  is  still  tolerably  lively,  and  takes 
his  food  with  appetite. 

This  state  of  things  may  continue  for  a  considerable  time,  often 
for  several  weeks,  or  even  months.  The  child  gradually  loses 
flesh,  and  becomes  paler,  and  more  languid ;  but  there  is  no  actual 
diarrhoea.  The  nurses,  on  being  questioned,  will  say  that  the 
bowels  are  "  nicely  open,"  and  it  often  requires  careful  cross-exa- 
mination of  the  attendants  to  discover  the  cause  of  the  loss  of  flesh. 
In  these  cases,  therefore  it  is  important  to  inspect  the  evacuations. 

After  a  time  the  stools  become  more  frequent  and  more  liquid ; 
but  vary  considerably  in  appearance  from  day  to  day.  At  one 
time,  they  are  thin,  watery,  and  brownish,  like  dirty  water ;  at 
others,  thicker,  and  clay-colored,  like  thin  mud ;  they  frequently 
contain  mucus,  free,  or  mixed  with  a  grumous  matter,  when  they 
are  called  "slimy"  by  nurses,  and  almost  always  present  little 
masses  of  undigested  food.  Occasionally  they  contain  particles  of 
grass-green  matter,  from  altered  blood,  an  indication  of  some  addi- 
tional irritation  of  the  bowel.  The  smell  becomes  more  putrid, 
and  is  often  exceedingly  offensive. 

When  the  diarrhoea  is  regularly  established,  the  tendency  of  the 
stools  is  to  become  more  and  more  liquid,  and  less  and  less  homo- 
geneous ;  but  there  is  no  regular  progression  from  bad  to  worse. 
There  are  alternations  of  improvement  and  relapse;  sometimes 
the  disease  is  better  for  a  day  or  two,  and  may  even  seem  almost 
cured ;  a  relapse  then  takes  place,  and  the  condition  of  the  child  is 
as  bad  as  before.  These  variations  in  the  intensity  of  the  diarrhoea 
will  often  be  found,  in  the  earlier  periods  of  the  disease,  to  coincide 
with  variations  in  the  temperature  and  humidity  of  the  air.  A 
damp,  chilly  day  is  usually  accompanied  by  increased  severity  of 
the  symptoms,  while  on  a  bright,  clear,  warm  day  the  disease  is 
better. 

The  child  begins  early  to  waste ;  but  unless  the  evacuations  are 
very  copious,  the  emaciation  does  not  progress  very  rapidly.  He 
gets  pale,  and,  after  a  time,  of  a  peculiar  earthy  tint  which  is  very 
characteristic.     The  skin  is  dry  and  harsh,  the  eyes  are  hollow,  the 


62  CHROXIC    DIARRHCEA. 

lips  pale  and  thin,  and  the  fontanelle  is  depressed.  His  strength 
diminishes,  and  as  the  disease  advances  he  seems  to  lose  all  power 
of  supporting  himself,  and  lies  like  a  log  in  his  cot,  or  on  his 
nurse's  lap.  Still,  the  appetite  is  usually  preserved,  and  he  will 
often  take  food  eagerly  whenever  it  is  offered ;  but  each  meal  is 
followed  by  a  notable  increase  in  the  diarrhoea.  His  food,  as  the 
nurses  say,  seems  "to  pass  through  him  directly  it  is  swallowed." 
The  tongue  is  moist,  often  quite  natural,  although  sometimes  the 
papillae  at  the  edges  and  tip  appear  unusually  red  and  prominent. 
The  belly  may  be  quite  flaccid  and  soft,  but  often  becomes  swollen 
and  tense  from  gas  generated  by  the  fermenting  food.  At  these 
times  there  is  some  pain,  shown  by  plaintive  cries,  by  uneasy 
movements  of  the  legs,  and  by  elevation  of  the  corners  of  the 
mouth.  Tenderness  may  also  be  present,  but,  until  the  disease  is 
far  advanced,  is  usually  inconsiderable. 

If  the  diarrhoea  continues,  the  wasting  becomes  more  and  more 
marked;  the  bones  project;  the  cheeks  get  hollow ;  the  forehead 
becomes  wrinkled  ;  and  the  aspect  generally  is  that  of  a  little,  infirm 
old  man.  The  wrinkling  of  the  forehead  is  due  to  loss  of  elasticity 
of  the  skin,  which  retains  the  folds  into  which  it  is  drawn.  The 
buttocks  and  inner  parts  of  the  thighs  become  red  from  eczema 
occasioned  by  the  irritation  of  the  urine  and  fecal  discharges.  The 
appetite  at  this  stage  may  be  preserved,  or  even  increased ;  but 
more  often  it  becomes  capricious,  and  the  child,  refusing  milk  and 
sop,  craves  for  beer,  or  for  the  more  tasty  articles  of  diet  which  he 
sees  eaten  around  him.  Sometimes,  however,  he  refuses  to  take 
any  nourishment  whatever.  All  this  time  there  is  no  fever.  In- 
deed, the  temperature  is  lower  than  is  natural,  being  often  no  more 
than  97.5  in  the  rectum. 

The  stools  are  now  excessively  frequent,  ten,  fifteen,  twenty,  or 
even  more,  in  the  four-and  twenty  hours ;  there  is  often  very  great 
straining  with  each  evacuation,  and  the  bowel  may  even  prolapse. 
The  motions  often  look  like  chopped  spinach  in  a  dirty-brown, 
stinking  water,  and  may  contain  blood — not  in  bright  red  streaks 
as  at  the  first,  but  of  a  dirty,  brownish-yellow  color,  and  mixed 
with  mucus  and  pus.  When  this  occurs,  and  there  is  at  the  same 
time  great  tenderness  of  the  belly  on  pressure,  with  gurgling,  the 
bowel  is  probably  ulcerated. 

There  are  certain  complications  liable  to  occur  in  this  disease 
which  often  hasten  the  end. 


COMPLICATIONS.  63 

Serous  effusions  mny  take  place  on  account  of  the  poverty  of  the 
blood,  and  the  relaxed,  attenuated  state  of  the  coats  of  the  vessels. 
They  begin  usually  at  the  feet,  which  hang  down  as  the  child  lies 
in  his  nurse's  lap.  The  instep  gets  quite  round,  and  feels  doughy  ; 
the  skin  over  it  is  thin,  and  looks  almost  transparent :  the  contrast 
thus  presented  between  the  thin  wasted  leg  and  the  bulbous  foot  is 
very  striking  and  peculiar.  The  backs  of  the  hands  and  the 
fingers  then  become  swollen,  and  occasionally  the  face  and  eyelids 
are  also  oedematous.  Effusions  may  also  take  place  into  the  serous 
cavities,  the  pleura,  peritoneum,  and  pericardium. 

Hypostatic  congestion  of  the  lungs  is  very  liable  to  occur,  for,  as 
the  child  lies  constantly  upon  his  back,  stasis  of  the  blood  takes 
place  in  the  most  depending  parts  of  his  lungs.  Death  is  not  at 
all  uncommon  from  this  cause.  For  the  same  reason,  pneumonia 
is  not  an  unfrequent  complication,  and,  if  the  child  is  very  much 
reduced,  may  exist  without  producing  cough,  or  any  of  the  other 
symptoms  by  which  its  presence  is  usually  manifested. 

TIlc  exayithemata  are  very  apt  to  attack  children  the  subjects  of 
this  disorder,  either  from  the  diminished  resisting  power  of  the 
system  induced  by  the  debility,  or  from  such  a  condition  as  ob- 
tains in  chronic  diarrhoea  being  especially  favorable  to  the  absorp- 
tion of  miasmatic  poisons. 

Convulsions  may  carry  off  the  child  early  in  the  disease.  They 
are  not,  however,  commonly  seen  in  the  later  stages.  Convulsions 
are  very  common  in  children  in  whom  there  is  a  sudden  depres- 
sion of  the  vital  powers,  and  are  therefore  frequently  seen  in  acute 
diarrhoea,  where  there  is  a  great  and  rapid  drain  upon  the  system. 
In  these  cases,  however,  where  the  debility  is  produced  more 
gradually,  although  a  greater  degree  of  prostration  may  be  reached, 
convulsions  are  rare,  for  the  child  then  assumes  some  of  the  physio- 
logical characters  of  old  age,  and  is  much  less  liable  to  be  affected 
by  reflex  stimuli. 

Tliromhosis  of  the  cerehral  sinuses  may  be  a  cause  of  death.  In 
these  cases,  the  child  dies  with  symptoms  of  suffocation,  or  falls 
into  a  state  of  stupor,  with  dilated  pupils,  occasional  strabismus, 
contraction  of  the  muscles  of  the  nape  of  the  neck,  fulness  of  one 
or  both  jugular  veins,  and  sometimes  paralysis  of  the  facial  nerve 
on  one  side  of  the  face. 

Some  interesting  cases  of  this  complication  are  given  by  Dr. 


6-i  CHRONIC    DIARRHCEA. 

You  Dusch,  in  his  paper  on  this  subject.^  On  post-mortem  exami- 
nation clots  are  found  in  one  of  the  sinuses — usually  the  longitu- 
dinal— plugging  its  channel.  These  clots  are  more  or  less  dis- 
colored, may  be  laminated  in  structure,  completely  fill  the  sinus, 
and  adhere  more  or  less  firmly  to  its  walls.  The  veins  opening 
into  the  obstructed  sinus  are  distended  with  blood. 

The  cause  of  the  plugging  is  thus  explained.  The  profuse 
watery  discharge  from  the  bowel  produces  inspissation  of  the  blood 
at  the  same  time  that  it  diminishes  its  quantity.  Absorption  of 
water  then  takes  place  from  the  substance  of  the  brain,  decreasing 
its  volume.  As  a  consequence,  the  fontauelle  sinks  in,  and  the 
bones  at  the  sutures  overlap  from  the  pressure  of  the  atmosphere 
endeavoring  to  fill  up  the  resulting  space.  If  this  is  not  enough 
to  compensate  for  the  lessened  volume  in  the  interior  of  the  skull, 
the  vessels  of  the  brain  and  the  sinuses  become  distended  with 
blood.  Now  the  rapidity  of  the  current  of  blood  in  the  sinuses  is, 
even  in  a  healthy  state  of  the  body,  comparatively  slight ;  partly 
on  account  of  the  dilatations  in  their  calibre,  and  the  projecting  par- 
titions in  their  walls ;  partly  on  account  of  the  increased  friction 
between  the  blood  and  the  sides  of  the  channel,  caused  by  the  an- 
gular form  of  the  sinuses.  If,  then,  this  natural  sluggishness  of 
the  current  is  increased  by  the  diminution  in  the  general  mass  of 
blood,  and  its  inspissation — which  result  from  the  diarrhoea,  and 
also  by  the  weakened  force  of  the  heart's  action — which  is  a  con- 
sequence of  the  debility,  we  have  a  condition  set  up  which  is 
particularly  favorable  to  the  occurrence  of  thrombosis  in  these 
sinuses. 

That  the  clotting  of  the  blood  is  not  a  post-mortem  change  is 
shown  by  the  color,  or  rather  want  of  color,  of  the  plug,  by  its 
laminated  structure,  and  by  the  fact  of  its  completely  filling,  and 
being  adherent  to,  the  sides  of  the  sinus.  That  it  is  not  due  to 
inflammation  is  shown  by  the  absence  of  all  traces  of  inflammation 
in  the  walls  around  it. 

"When  the  disease  terminates  fatally,  the  child  often  dies  from 
one  of  the  above  causes.  Sometimes,  however,  he  sinks  and  dies 
without  our  being  able  to  say  that  any  of  these  complications  are 
present.     In  these  cases  the  emaciation  becomes  extreme.     The 

'  New  Sydenham  Society.     ISGl. 


DEATH    WITHOUT    COMPLICATIONS.  65 

eyes,  deeply  sunken  in  their  sockets,  have  a  dull,  ghastly  look ;  the 
cheek-bones  project ;  the  cheeks  sink  in ;  the  nose  looks  sharpened ; 
a  furrow  passes  on  each  side  from  the  upper  part  of  the  ala  of  the 
nose,  and  forms  a  rough  semicircle  round  the  corners  of  the  mouth  , 
the  lips  are  red,  cracked,  and  covered  with  sordes ;  and  the  inside 
of  the  cheek  and  lips,  and  the  surface  of  the  tongue,  become 
aphthous,  or  are  covered  with  thrush.  The  tongue  becomes  dry, 
and,  when  free  fyom  thrush,  is  apt  to  have  a  granular  appearance 
from  projecting  papillae.  The  complexion  is  dull  and  earthy 
looking,  and  the  skin  seems  tightened  over  the  projecting  bones  of 
the  face.  The  fontanelle  is  deeply  depressed.  The  body  gener 
ally  appears  to  consist  of  little  more  than  the  bones  covered  by  the 
dry,  rough,  flaccid  skin ;  each  rib  stands  out  sharp  and  distinct  on 
the  wasted  chest.  The  belly  may  be  flaccid,  but  more  usually  is  full 
and  prominent,  as  the  emaciated  and  relaxed  walls  yield  before 
the  pressure  of  the  flatus  in  the  bowels.  The  skin  of  the  abdomen 
becomes  of  a  dirty-brown  color,  or  is  speckled  with  brownish  spots. 
The  feet  and  hands  are  cold,  and  often  look  purple  even  when  not 
actually  cold  to  the  touch.  The  child  lies  quiet,  with  eyes  half 
closed  and  dim.  Occasionally  he  draws  up  the  corners  of  his  lips, 
and  wrinkles  his  brow  as  if  to  cry,  but  makes  no  sound ;  but  for 
this  plaintive  sign,  and  for  his  slow,  quiet  breathing,  he  might  be 
thought  to  be  dead.  In  these  cases,  death  takes  place  almost 
without  a  struggle,  and  it  is  often  difficult  to  say  at  what  precise 
moment  the  child  ceases  to  exist. 

Sometimes  for  a  few  days  before  death  the  evacuations  entirely 
cease,  but  no  false  hopes  should  be  raised  by  this  change,  if  a 
corresponding  amendment  does  not  take  place  in  the  general  symp 
tomgf 

In  cases  of  recovery,  the  stools  gradually  become  more  homo 
geneous,  more  solid,  and  more  fecal,  and  one  great  sign  of  improve- 
ment is  the  reappearance  of  bile  in  the  stools.  The  child  at  the 
same  time  becomes  less  torpid  ;  his  eyes  grow  brighter ;  he  grows 
intensely  fretful,  and  manifests  his  uneasiness  by  crying.  The 
reappearance  of  tears  is  a  very  favorable  symptom,  and  one  which 
allows  us  to  entertain  strong  expectations  of  his  ultimate  recovery. 
He  ceases  to  emaciate,  and  soon  begins  to  regain  flesh — very 
slowly  at  the  first,  and  the  earliest  advance  in  this  respect  is  seen 
about  the  buttocks,  which  will  be  noticed  to  have  become  a  little 
fuller  and  more  rounded.  The  stools  gradually  lose  their  fetid 
5 


66  CHRONIC    DIARRHCEA. 

character,  get  more  healthy-looking,  and  constipation  usually  re- 
places the  previous  purging. 

Although  the  nutrition  of  the  body  is  so  much  interfered  with 
in  this  disease,  and  the  child  daily  emaciates  more  and  more,  yet 
it  is  exceedingly  curious  to  find  how  in  certain  cases — usually  the 
less  severe  ones — the  growth  and  development  of  the  teeth  may 
continue  in  spite  of  the  general  condition.  In  the  cases  in  which 
this  occurs  the  teeth  are  for  the  most  part  cut  easily,  and  without 
any  apparent  aggravation  of  the  other  symptoms.  Nor  does  the 
eruption  of  each  tooth  appear  to  be  accompanied  by  any  special 
improvement  which  can  be  attributed  to  that  as  its  cause.  Denti- 
tion goes  on  rapidly  and  easily,  while  the  diarrhoea  remains  sta- 
tionary, or  slowly  improves.  These  cases  generally  recover.  In 
an  infant  of  eight  months  old  whom  the  author  attended  for  this 
complaint,  five  incisor  teeth  made  their  appearance  in  the  course 
of  a  month.  The  child  got  well.  From  this  consideration  we 
may  conclude  that  the  common  idea  which  associates  this  disease 
with  dentition,  as  a  result  of  the  cutting  of  the  teeth,  is  one  en- 
tirely without  foundation.  Dr.  Cheyne,^  who  first  described  this 
disorder,  under  the  name  of  atrophia  lactantium,  or  the  weaning 
brash,  also  takes  this  view.  He  states  that  this  disease  is  often 
in  cases  where  there  is  no  swelling  or  inflammation  of  the  gums, 
no  salivation  nor  any  appearance  of  pain  or  tenderness  about  the 
mouth,  in  cases  where  the  child  is  cutting  his  teeth  easil}'",  and 
even  in  children  of  three  months  old,  who  have  no  teeth  at  all. 
We  shall  see  that  it  may  begin  almost  at  birth. 

Causes. — Chronic  diarrhoea  may  usually  be  traced  to  three  dif- 
ferent sets  of  causes,  viz.,  bad  hygienic  conditions,  impressions  of 
cold,  and  the  occurrence  of  some  previous  acute  disease.        • 

The  disorder  is  very  apt  to  attack  children  who  are  exposed  to 
bad  hygienic  conditions,  and  the  younger  the  infant  at  the  time 
when  these  injurious  influences  are  at  work,  the  more  liable  is  he 
to  suffer  from  their  effects  in  this  particular  way. 

Improper  food  has  already  been  strongly  insisted  on  as  a  cause 
of  defective  nutrition  in  the  child,  and  by  the  weakness  which  it 
invariably  induces  would  alone  render  him  less  able  to  resist  any 
other  pernicious  agencies  to  which  he  might  be  exposed.  But  in 
addition,  the  continued  passage  along  the  bowels  of  masses  of  in- 

•  Second  Essay  on  Diseases  of  Children.     By  John  Clieyne,  M.  D.     1802. 


CAUSES.  67 

digestible  food  must  cause  constantly  renewed  irritation  to  bis 
delicate  mucous  membrane,  and,  if  the  same  diet  be  persisted  in, 
must  lead  in  time  to  diarrhoea.  When  due  to  this  cause,  there  are 
three  periods  at  which  the  disease  is  most  usually  found  to  mani- 
fest itself. 

If  the  cliild  be  brought  up  by  hand  he  may  be  subject  to  it  from 
his  very  birth.  In  these  cases  the  infant  not  only  does  not  grow, 
but,  as  his  fat  gradually  disappears,  he  seems  even  to  become 
smaller  and  more  puny.  It  is  not  uncommon  for  a  mother  to  say, 
speaking  of  a  child  of  two  or  three  months  old,  who  all  his  short 
life  has  been  suffering  from  this  complaint,  "  No  food  seems  to  do 
him  any  good ;  he  is  smaller  than  when  he  was  born." 

If  the  mother  is  able  to  nurse  her  child,  he  often  goes  on  well 
for  four  or  five  months,  but  then  being  supplied  with  other  and 
less  digestible  food,  as  an  addition  to  the  breast- milk — food  which 
is  often  ill-selected,  and  consists,  not  unfrequently,  of  portions  of 
the  meals  of  his  parents — he  begins  to  waste,  and  the  diarrhoea  is 
set  up. 

The  third  period  at  which  this  disorder  is  apt  to  show  itself  is 
the  time  of  weaning ;  and  so  frequently  is  this  the  case,  that  the  dis- 
ease has  obtained  the  name  of  atrophia  lactantium.  It  is  at  this 
time  Avhen,  the  simple  food  on  which  he  has  hitherto  principally 
subsisted  being  withdrawn,  he  is  so  exposed  to  danger  from  the 
mistaken  kindness  of  his  attendants,  who,  confusing  substantial 
with  nutritious  food,  supply  him  with  articles  of  diet  which  they 
consider  suitable  to  his  requirements,  because  they  know  them  to 
be  sufficient  for  their  own.  The  length  of  time  during  which 
children,  amongst  the  poorer  classes,  are  suckled  in  this  country, 
also  favors  the  result  described.  The  infant  is  often  kept  at  the 
breast  long  after  there  is  any  nourishment  to  be  obtained  from  his 
mother's  milk.  The  degree  of  weakness  to  which  he  is  reduced 
by  such  a  system  enfeebles  his  digestive  power,  and  prevents  him 
from  assimilating  even  such  a  diet  as,  were  he  in  health,  would 
afford  him  the  nourishment  he  requires. 

Even  while  at  the  breast  the  infant  is  not  exempt  from  danger. 
Hired  nurses,  in  whom  the  breast  milk  is  not  sufficient  in  quantity 
or  quality  for  the  child's  support,  will  often  feed  him  secretly 
with  farinaceous  or  other  food,  in  order  that  this  deficiency  may 
pass  undetected.  This  is  not  an  uncommon  source  of  disease  in 
very  young  infants.     In  these  cases  it  is  difficult  to  extort  a  con- 


68  CHRONIC    DIARRHCEA. 

fession  from  the  nurse,  but  our  suspicions  are  often  verified  by  a 
microscopic  examination  of  the  stools,  when  starch  granules  will 
be  found  in  large  numbers. 

Bad  air,  want  of  sunlight,  and  want  of  cleanliness,  are  also 
fruitful  sources  of  this  disease,  especially  when,  as  is  usually  the 
case,  they  are  combined  with  the  preceding.  The  crowding  to- 
gether of  children  in  rooms,  where  they  live  and  sleep  in  a  close 
atmosphere,  is  a  frequent  cause  of  derangements  of  the  stomach 
and  bowel ;  and  amongst  French  authors  residence  in  a  hospital  is 
systematically  included  amongst  the  causes  which  increase  the 
gravity  of  these  disorders.  In  an  institution  with  which  the 
author  has  been  for  several  years  connected,  founded  for  the  tem- 
porary reception  of  single  women  with  their  offspring,  it  was 
noticed  that  when  the  occupants  of  the  infants'  sleeping  nursery 
reached  a  certain  number,  one  or  two  deaths  were  certain  to  occur 
from  bowel  complaints,  and  this  in  spite  of  all  possible  precautions 
in  the  way  of  ventilation,  etc.  It  was  only  by  making  arrange- 
ments for  distributing  the  number  amongst  several  rooms  that  this 
mortality  could  be  avoided. 

Chilling  of  the  surface  is  another  common  cause  of  diarrhoea. 
This  will  be  afterwards  discussed  under  the  head  of  "  Prevention." 

The  diseases  which  lead  especially  to  this  disorder  are  measles, 
scarlatina,  variola,  pneumonia,  typhoid  fever,  croup,  bronchitis, 
angina,  and  pleurisy.  MM.  Rilliet  and  Barthez^  found  that  out  of 
140  cases  of  secondary  chronic  diarrhoea  in  children,  37  had  been 
preceded  by  measles,  27  by  pneumonia,  17  by  typhoid  fever, 
variola,  and  scarlatina,  respectively,  and  29  by  the  other  diseases 
which  have  been  mentioned.  Of  this  number,  only  21  cases  were 
cured ;  the  others  proved  fatal. 

In  older  children  the  presence  of  the  ascaris  lumbricoides  in  the 
alimentary  canal  will  give  rise  to  a  diarrhoea  which  may  continue 
for  months,  now  better,  now  worse,  and  only  be  finally  arrested  by 
the  expulsion  of  the  worm.  In  these  cases  the  diarrhoea  is  most 
troublesome  at  night,  the  bowel  during  the  day  being  much  less 
disturbed,  and  is  accompanied  by  great  straining,  and  often  by 
prolapsus  ani. 

Besides  the  causes  which  have  been  mentioned,  chronic  diar- 
rhoea may  have  also  a  tubercular  origin,  arising,  however,  not 

'  Traite  des  Maladies  des  Enfauts.     Paris,  1861. 


ANATOMICAL    CHARACTERS.  69 

directly  as  a  consequence  of  the  tubercle,  but  as  a  consequence  of 
the  inflammation  and  ulceration  which  the  presence  of  the  tubercle 
excites.  It  usually  occurs  in  children  who  are  suffering  at  the 
same  time  from  mesenteric  phthisis  or  tubercular  peritonitis,  of 
which  diseases  the  presence  of  this  complication  very  greatly  in- 
creases the  danger.  Tuberculous  diarrhoea  is  very  rare  in  infants, 
and  is  most  common  in  children  between  the  ages  of  six  and  ten 
years. 

Anatomical  Characters. — Not  unfrequently  on  opening  the  bowel 
after  death  we  find  absolutely  nothing  at  all  to  account  for  the 
serious  nature  of  the  disease:  the  alimentary  canal  may  have  a 
perfectly  sound  appearance  from  one  end  to  the  other. 

In  other  cases  we  find  the  mucous  membrane  of  the  large  intes- 
tine studded  with  fine,  dark-colored  points,  giving  the  so-called 
"cut-beard  appearance" — an  appearance  which  is  due  to  a  ring  of 
congestion  round  the  openings  of  the  little  follicles. 

In  other  cases,  again,  the  mucous  membrane  of  the  large  intes- 
tine may  be  inflamed.  The  inflammation,  however,  is  seldom  gen- 
eral; it  is  usually  limited  to  the  summits  of  the  longitudinal  folds 
into  which  the  lining  membrane  of  the  bowel  is  thrown. 

Lastly,  the  mucous  membrane  may  be  not  only  inflamed,  but 
ulcerated.  The  ulcers  are  shallow,  and  are  often  difficult  to  detect 
except  by  looking  sideways  at  the  surface,  for  their  bases  are  of 
the  same  color  as  the  parts  around  them.  They  may  occupy  either 
the  summits  of  the  longitudinal  folds — when  they  are  elongated 
and  sinuous,  or  may  be  situated  between  the  folds — when  they  are 
very  small  and  circular. 

The  ulcers  no  doubt  result  from  the  breaking  down  of  follicles 
which  had  been  previously  enlarged  by  cell  proliferation  and  had 
undergone  cheesy  transformation.  Mixed  up  with  the  ulcers  we 
see  the  solitary  glands  and  follicles  enlarged  and  elevated  above 
the  surface,  looking  like  little  transparent  pearls.  The  same 
pearly  appearance  of  enlarged  follicles  is  often  seen  during  life  on 
the  inside  of  the  mouth  dotting  the  mucous  membrane  of  the 
cheek. 

The  mucous  membrane,  when^  much  inflamed,  is  often  exceed- 
ingly soft,  and  may  be  much  thickened.  M.  Bouchut,  however,  states 
that  where  the  disease  is  very  chronic,  and  there  is  great  emacia- 
tion, the  lining  membrane  becomes  thin,  and  in  some  cases  hardly 
seems  to  exist  all. 


70  CHRONIC    DIARRHCEA. 

These  changes  are  sometimes  found  to  extend  into  the  small  in- 
testine, which  may  be  inflamed  or  ulcerated  for  a  short  distance 
above  the  ilio-csecal  valve,  but  in  the  large  majority  of  cases  the 
lesions  are  limited  to  the  colon. 

The  mesenteric  glands  are  occasionally  swollen,  but  otherwise 
appear  unchanged  in  structure. 

It  is  probable  that  these  appearances  depend  upon  the  passage 
over  the  mucous  membrane  of  the  larger  bowel  of  the  acrid  secre- 
tions poured  out  by,  and  descending  from,  the  small  intestine.  The 
contact  of  these  matters  irritates  the  gut  in  the  same  way  that  the 
skin  over  the  buttocks  and  inner  part  of  the  thighs  is  irritated  by 
the  same  fluids  when  they  have  been  ejected  from  the  body. 

Tubercle  of  the  bowels  is  seen  as  small  gray  or  yellow  granula- 
tions beneath  the  mucous  membrane.  They  may  occupy  the 
whole  extent  of  both  small  and  large  intestines,  but  are  usually  in 
the  greatest  quantity  in  the  smaller  gut,  especially  that  part  of  it 
which  is  just  above  the  ilio  caecal  valve. 

The  presence  of  the  tubercle  excites  inflammation,  which  ex- 
tends through  the  thickness  of  the  wall  of  the  bowel,  and  may 
glue  the  serous  coat  to  contiguous  parts,  so  that  coils  of  intestine 
are  matted  together,  and  are  oftent  adherent  to  the  peritoneal  lining 
of  the  abdominal  wall. 

The  mucous  membrane  ulcerates,  and  the  ulcers  are  circular  or 
oval,  with  uneven,  jagged  edges,  red,  soft,  thick,  and  rather  de- 
tached ;  underneath  the  borders  are  seen  tubercles,  either  crude  or 
softened.  The  ulcers  vary  much  in  size  :  when  oval  or  elongated, 
their  greater  diameter  lies  transversely.  The  floor  of  the  ulcer  is 
red  or  grayish,  and  is  formed  by  different  coats  of  the  intestine,  ac- 
cording to  the  depth  to  which  the  ulceration  has  extended.  Some- 
times they  penetrate  as  deeply  as  the  peritoneal  covering  of  the 
bowel ;  but  extravasation  into  the  peritoneal  cavity  is  rare,  on 
account  of  the  thickening  of  the  tissue  at  the  base  of  the  ulcer, 
and  the  adhesions  which  are  formed  with  the  parts  around. 

Diagnosis. — It  is  very  important  to  distinguish  the  variety  of 
diarrhoea  with  which  we  have  to  deal:  whether  it  is  due  to  a  sim- 
ple catarrh  of  the  intestines,  or  i^  dependent  upon  a  tuberculous 
ulceration  of  the  bowels.  To  determine  this  question  we  must 
consider  the  age  of  the  child,  the  circumstances  under  which  the 
purging  commenced,  and  the  existence  of  tubercle  in  other  organs. 
Tuberculous  diarrhoea  is  exceedingly  uncommon  during  the  first 


DIAGNOSIS — PROGNOSIS.  71 

year,  or  even  the  first  two  years  of  life,  and  therefore  the  occur- 
rence of  purging  at  this  time  argues  against  its  being  due  to  tu- 
bercle. 

If  the  disease  began  a  few  days  after  birth,  or  its  commencement 
can  be  distinctly  connected  with  weaning,  or  with  the  administra- 
tion of  unsuitable  food,  the  case  is  probably  one  of  simple  intesti- 
nal catarrh. 

If  it  occur  in  older  children,  the  other  organs  should  be  care- 
fully examined  for  signs  of  tubercle.  The  existence,  especially, 
of  mesenteric  phthisis,  or  of  tubercular  peritonitis,  renders  the 
same  condition  of  the  bowel  exceedingly  probable.  Even  in  these 
cases,  however,  we  cannot  be  sure  of  the  correctness  of  our  diag- 
nosis, for  tubercle  of  other  organs  may  be  complicated  by  a  simple 
catarrh  of  the  bowels.  When  thus  in  doubt  as  to  the  presence  or 
absence  of  tubercle,  the  thermometer  becomes  of  great  service. 
In  simple  chronic  diarrhoea  the  temperature  is  lower  than  in  health, 
and  does  not  become  elevated  in  the  evening.  If  then  there  should 
be  found  persistent  elevation  of  temperature  at  night,  without  any 
cause  such  as  teething  or  any  external  irritation  to  which  the  ele- 
vation can  be  attributed,  the  presence  of  tubercle  becomes  a  matter 
of  the  very  strongest  suspicion.  While,  on  the  other  hand,  a  low 
temperature  in  the  evening  affords  just  grounds  for  believing  that 
we  have  to  deal  only  with  an  ordinary  case  of  chronic  functional 
derangement. 

Another  important  test  is  the  result  of  treatment.  Tuberculous 
diarrhoea  is  so  fatal,  that  if  the  child  recovers,  and  especially  if 
the  purging  is  found  to  be  arrested  by  an  alteration  of  diet,  or 
by  a  return  to  the  breast,  its  non-tuberculous  origin  is  at  once 
established.  The  converse  of  this,  however,  is  not  equally  true. 
If  the  disease  resists  all  treatment,  it  is  not  therefore  necessarily 
tuberculous.  Simple  chronic  diarrhoea,  as  has  already  been  stated, 
is  very  frequently  fatal. 

When  the  child,  after  cessation  of  the  diarrhoea  and  the  com- 
mencement of  convalescence,  suddenly  ceases  to  improve,  the 
presence  of  some  complication  should  be  suspected.  In  such 
cases  the  lungs  should  be  always  carefully  examined  for  pneumo- 
nia. 

Prognosis. — Chronic  diarrhoea,  when  it  becomes  confirmed,  is 
exceedingly  fatal,  but  so  long  as  it  remains  uncomplicated  we  may 
entertain  some  hopes  of  a  favorable  termination. 


72  CHRONIC    D1ARRH(EA. 

When  secondary  to  some  acute  disease,  the  case  is  graver  than 
when  it  is  primary  and  non-febrile  from  the  first. 

When  it  is  due  unmistakably  to  error  in  feeding,  we  may  hope 
by  a  change  in  the  diet  to  arrest  the  purging  before  any  organic 
lesion  has  been  set  up  in  the  alimentary  canal. 

The  form  of  stool  which  is  of  worst  augury  is  that  composed  of 
greenish  matter,  like  chopped  spinach,  in  dirty-brown,  stinking- 
fluid,  and  mixed  with  purulent  mucus  and  blood.  The  putridity 
here  results  from  decomposition  of  the  albumen  in  the  serum, 
while  the  purulent  and  bloody  matters,  especially  if  there  is  at  the 
same  time  great  tenderness  on  pressure  of  the  abdomen,  indicate 
ulceration  of  the  mucous  membrane  of  the  large  intestine.  The 
thicker  and  more  homogeneous  the  motions  become,  although  they 
may  at  the  same  time  remain  intensely  ofi'ensive,  the  more  favor- 
able is  the  prognosis. 

The  occurrence  of  any  complication  should  give  rise  to  very 
great  anxiety.  Measles  especially  is  apt  to  cause  a  sudden  and 
violent  increase  in  the  intensity  of  the  diarrhoea,  and,  besides,  its 
own  course  is  often  rendered  irregular  by  the  presence  of  the  in- 
testinal disorder,  so  that  retrocession  of  the  eruption  and  other 
alarming  symptoms  may  ensue. 

The  prognosis  is  also  rendered  very  unfavorable  if  the  tongue 
become  dry  and  rough,  if  thrush  appear  upon  the  inside  of  the 
mouth,  or  if  dropsy  occur.  If  tubercle  can  be  detected  in  other 
organs,  the  diarrhoea  is  in  all  probability  due  to  tuberculous  ulcera- 
tion of  the  bowels:  death  is  in  all  cases  almost  certain. 

Amongst  the  favorable  signs  may  be  included — continuance  of 
the  natural  progress  of  dentition,  the  appearance  of  tears,  and  the 
occurrence  of  any  eruption  ^  (unconnected,  of  course,  with  any  of 
the  exanthemata)  upon  the  child's  body,  even  although  the  diarrhoea 
may  not  at  the  time  have  undergone  any  visible  improvement. 

Prevention. — Diarrhoea  may  be  prevented  by  attention  to  the 
diet  and  general  management  of  the  child.  All  indigestible  food 
is  calculated,  in  its  passage  through  the  bowels,  to  give  rise  to 
irritation,  and  therefore  to  cause  an  increased  flow  of  watery  fluid 
from  the  vessels  of  the  intestines.  It  is  unnecessary  to  repeat  here 
the  directions  which  have  been  already  given  for  the  feeding  of 
young  children,  and  the  reader  is  referred  to  the  section  on  the 

•  Underwood,  he.  cit.  '. 


PREVEXTIOX.  73 

treatment  of  simple  atrophy  for  full  information  upon  this  subject. 
It  may,  however,  be  remarked  that  the  practice  of  giving  to  very 
young  children  sweet  cakes,  and  articles  of  confectionery,  between 
their  regular  meals,  and  as  rewards  for  good  behavior,  is  one  to  be 
very  strongly  deprecated.  Sweet  cakes  are  especially  to  be 
avoided,  as  they  are  so  apt  to  undergo  fermentation  in  the  ali- 
mentary canal. 

As  cold  is  so  common  a  cause  of  diarrhcea  in  children,  great 
care  should  be  taken  to  shield  them  from  this  source  of  danger. 
But  they  should  not,  therefore,  be  confined  too  strictly  to  the  house. 
Fresh  air  is  as  important  to  them  as  simple  nourishing  food. 
Healthy  infants  should  be  taken  out  at  certain  periods  of  the  day 
whenever  the  weather  permits.  It  is  not  so  much  cold  as  damp 
air  which  is  dangerous  to  infants,  and  even  in  damp  air,  unless  it 
be  actually  raining,  a  short  expedition  is  not  hurtful  to  a  robust 
child,  provided  sufficient  precautions  be  taken.  The  child  should 
be  warmly  dressed,  should  be  walked  briskly  about,  and  should 
not  be  allowed  to  remain  out  too  long  at  a  time.  If  there  is  any 
wind  his  face  should  be  protected  with  a  woollen  veil.  As  an 
additional  defence,  a  flannel  bandage  should  be  worn  round  the 
body  next  to  the  skin.  This  is  an  article  of  clothing  no  infant  or 
young  child  should  be  without.  It  should  be  looked  upon  as  a 
necessary  part  of  his  dress.  The  band  should  be  sufficiently  wide 
to  cover  the  whole  belly  from  the  pubes  to  the  ensiform  cartilage, 
and  long  enough  to  go  twice  round  the  body.  It  should  be 
secured  by  buttons  or  by  tapes,  not  by  pins  ;  and  in  fitting  it  care, 
should  be  taken  to  wrap  the  bandage  tightly  round  the  crests  of 
the  ilia  so  that  it  may  not  slip  up  and  leave  the  lower  part  of  the 
bell}^  exposed.  The  band  is  more  elastic  if  cut  diagonally  from 
the  piece  of  flannel. 

Sudden  changes  of  temperature  are  especially  to  be  avoided, 
and  a  rapid  change  from  cold  to  heat  appears  to  be  as  prejudicial 
as  a  similar  passage  from  heat  to  cold.  It  is,  therefore,  necessary 
to  prevent  an  infant  being  taken  too  quickly  to  a  hot  fire  after 
exposure  to  the  cold  of  the  outside  air.  The  child  should  not  be 
allowed  to  wait,  clothed  in  his  out-door  dress,  in  a  warm  room 
before  taking  his  airing.  He  should  be  taken  out  directly  he  is 
dressed  for  the  walk.  While  out,  he  should  be  kept  in  movement, 
and  should  not  be  allowed  to  remain  motionless  in  a  current  of 
cold  air.     If  able  to  walk,  he  should  be  placed  from  time  to   time 


74  CHROXIC    DIARRHCEA. 

upon  bis  feet,  and  be  allowed  to  trot  along  holding  the  hand  of  his 
nurse.  If  the  weather  is  cold,  damp,  and  gloomy,  he  should  be 
brought  back  to  the  house  after  only  a  short  stay  in  the  open  air. 
A  pinched  look  about  the  face,  with  coldness  and  blueness  of  the 
extremities,  are  certain  signs  that  he  is  no  longer  receiving  benefit 
from  his  airing. 

Bathing  the  chest  and  belly  in  the  morning,  on  first  rising  from 
bed,  with  equal  parts  of  vinegar  and  water,  or  with  a  mixture  of 
one  part  of  vinegar,  one  of  eau-de-cologne,  and  two  of  water,  is 
said  to  diminish  the  susceptibility  of  the  body  to  the  impression 
of  cold.     This  is  worth  trying  in  weakly  children. 

During  dentition  the  rules  here  laid  down  must  be  especially 
observed,  for  it  is  at  such  times,  when  the  teeth  are  pressing 
through  the  gum.  that  diarrhoea  is  so  common.  Many  children 
are  said  always  to  cut  their  teeth  with  diarrhcea.  Perhaps,  how- 
ever, dentition  in  these  cases  is  not  so  entirely  to  blame  as  is 
commonly  supposed.  ISTo  doubt,  during  the  cutting  of  the  teeth 
the  bowels  generally  are  in  a  state  of  irritability,  for  we  know 
that  at  these  periods  the  follicular  apparatus  of  the  intestines  is 
undergoing  considerable  development.  The  bowels  then  are  ripe 
for  diarrhoea ;  there  is  increased  sensitiveness  to  the  ordinary  ex- 
citing causes  of  purging ;  but  without  the  presence  of  these  ex- 
citing causes  diarrhoea  is  by  no  means  a  necessary  result  of  such  a 
condition  of  the  alimentary  canal.  "We  find  that  looseness  of  the 
bowels  is  a  more  common  accompaniment  of  dentition  in  summer 
and  autumn  than  in  winter ;  that  is,  at  a  season  when  the  changes 
of  temperature  are  so  rapid  and  unexpected,  and  when  therefore 
the  child  is  particularly  exposed  to  sudden  chills,  rather  than  at  a 
time  of  the  year  when  the  temperature,  though  lower,  is  more 
uniformly  low,  and  when  precautions  are  more  naturally  taken 
against  the  cold.  Dentition,  too,  commences  at  a  period  when  the 
child  is  beginning  to  require  additional  food  besides  that  furnished 
by  his  mother's  milk,  and  consequently  at  a  time  when  he  is  so 
liable  to  be  supplied  with  articles  of  diet  unsuited  to  his  age. 
Even  if  the  diet  be  a  suitable  one  for  the  infant  when  in  health,  it 
by  no  means  follows  that  the  same  regimen  should  be  found  equally 
appropriate  at  a  time  when  the  febrile  irritation  set  up  by  the  ad- 
vancing tooth  has  temporarily  reduced  his  digestive  power.  His 
ordinary  diet  may  then  become  indigestible,  and  therefore  irri- 
tating: to  his  bowels. 


TREATMENT — CLEANLINESS.  7o 

Treatment. — The  marked  influence  exercised  upon  chronic  diar- 
rho3a  in  children  by  variations  in  the  temperature  and  degree  of 
moisture  of  the  air  indicates  an  important  means  of  checking  the 
disease. 

The  infant  must  be  kept  as  nearly  as  possible  in  an  equable 
temperature  of  from  60°  to  65°  Fahrenheit.  Free  ventilation  must 
be  sustained  by  an  open  fire,  or  in  warm  weather  by  a  lamp  placed 
in  the  chimney  ;  but  all  draughts  of  air  should  be  carefully  guarded 
against.  Where  practicable,  two  adjoining  rooms,  having  a  door 
of  communication  between  them,  should  be  chosen.  The  child 
may  then  inhabit  them  alternately,  and  during  his  absence  the  un- 
occupied apartment  can  be  freely  ventilated.  Even  where  this 
convenience  is  unattainable,  two  rooms,  although  separated  from 
one  another  by  a  passage,  should  be  always  made  use  of:  the  child 
can  be  taken  from  one  to  the  other  without  danger  if  wrapped 
from  head  to  foot  in  a  blanket.  At  night,  air  should  be  admitted 
into  the  room  as  freely  as  is  consistent  with  the  avoidance  of 
draughts  ;  with  this  object,  the  door  of  the  room  may  be  left  open, 
or  in  dry  warm  weather  the  window  may  be  opened  for  a  short 
distance  at  the  top.  In  damp  weather,  however,  or  in  seasons 
when  the  temperature  falls  notably  at  sunset,  this  must  be  pro- 
hibited. If  possible,  the  infant  with  his  nurse  should  be  the  only 
occupants  of  the  bed-room,  and  no  cooking  of  any  kind  should  be 
allowed  in  either  nursery. 

The  most  scrupulous  cleanliness  must  be  observed.  The  nates 
should  be  carefully  sponged  and  dried  after  each  motion,  and 
should  then  be  dusted  over  with  powdered  h^copodium,  or,  if  the 
skin  is  abraded,  with  equal  parts  of  this  and  of  powdered  oxide  of 
zinc ;  while  the  whole  bod}'-  should  be  bathed  twice  a  day  with 
warm  water.  All  soiled  napkins  must  be  at  once  removed  from 
the  room,  and  the  night-cot  and  bedding  should  be  taken  away 
every  morning  and  be  freely  exposed  to  the  air. 

If  a  flannel  bandage  have  "not  been  previously  in  use,  it  must  be 
at  once  applied  as  directed  above.  This  precaution  should  on  no 
account  be  neglected.  Flannel,  which  is  a  non-conductor,  forms 
by  far  the  most  efl&cient  protection  to  the  belly  against  sudden 
changes  of  temperature.  Chronic  diarrhoea  is,  no  doubt,  frequently 
kept  up  by  a  succession  of  chills,  just  as  a  coryza  or  pulmonary 
catarrh  may  be  prolonged  almost  indefinitely  by  the  same  means. 
By  the  use  of  this  safeguard,  we  at  any  rate  insure  ourselves  from 


76  CHRONIC    DIARRHCEA. 

having  to  deal  with  a  series  of  catarrhs.  For  the  same  reason  tlie 
feet  and  legs  should  be  covered  with  woollen  stockings.  It  is  well 
known  that  cold  feet  have  a  very  bad  effect  on  irritable  stomach 
and  bowels;  and  in  children,  otherwise  healthy,  often  produce 
severe  pain  in  the  belly.  In  a  child  suffering  apparently  from  ab- 
dominal pains  the  feet  should  always  be  examined,  and  if  cold,  it 
is  usually  found  that  on  warming  them  the  manifestation  of  pain 
ceases. 

The  next  thing  is  carefully  to  regulate  the  diet.  In  chronic 
diarrhoea  children  are  often  excessively  ravenous,  and  the  mothers 
and  nurses,  true  to  their  principle  of  giving  the  most  solid  food 
to  the  weakest  children,  are  in  all  probability  filling  him  with 
everything  that  is  most  calculated  by  its  indigestible  properties  to 
aggravate  his  abdominal  derangement.  "The  child,"  they  say, 
"will  eat  anything,"  and  they  give  him  "  anything"  accordingly. 
All  this  must  be  at  once  put  a  stop  to,  and  the  diet  of  the  child  must  . 
be  so  arranged  that  he  will  still  be  nourished,  while  the  demands 
upon  his  digestive  power  are  reduced  to  a  minimum.  In  all  cases, 
if  the  infant  be  at  the  breast,  he  should  be  limited  strictly  to  it. 
If  he  have  been  lately  weaned,  the  breast  should  be  returned  to. 
Even  if  he  have  been  weaned  some  months,  the  plan  is  still  often 
of  service ;  but,  under  such  conditions,  the  child  frequently  refuses 
the  breast,  and  no  persuasions  can  induce  him  to  return  to  this  mode 
of  feeding.  In  these  cases,  therefore,  or  in  cases  where  from  any 
reason  a  return  to  the  breast  is  impossible,  our  great  trust  should 
be  placed  in  cow's  milk  more  or  less  copiously  diluted  with  lime- 
water.  The  diet,  however,  will  vary  considerably  according  to  the 
age  and  strength  of  the  child,  and  also  according  to  the  character 
of  the  stools.  Thus  for  a  child  under  six  months  old  nothing 
should  be  allowed  but  milk  or  some  preparation  of  milk,  as  milk 
and  lime-water  (equal  parts),  whey  with  cream,  or  milk  and  water 
thickened  with  isinglass,  in  the  proportion  of  a  teaspoonful  to  four 
ounces.  Cases,  however,  are  sometimes  met  with  in  which  no 
milk  can  be  borne  :  these  will  be  considered  afterwards.  Farina- 
ceous food  should,  as  a  rule,  be  rigidly  excluded  from  the  diet  of 
infants  under  six  months  old ;  but  Liebig's  food  for  infants  (Mel- 
lin's)  may  be  allowed,  and  is  often  well  digested  in  quantities  of  one 
teaspoonful  to  four  ounces  of  milk  and  water.  By  the  above  means 
the  successive  meals  can  be  made  to  vary  in  character,  and  they 
should  be  so  regulated  that  the  quantity  taken  on  each  occasion,  and 


DIET.  77 

the  length  of  the  intervals  by  which  the  meals  are  separated,  may 
be  properly  proportioned  to  one  another  and  to  the  state  of  the 
patient.  The  more  copious  the  diarrhoea,  the  smaller  should  be 
the  meals,  and  the  more  frequently  should  they  be  repeated ;  for 
any  large  quantity  of  liquid  food  taken  at  once  would  be  directly 
absorbed  from  the  stomach  into  the  circulation,  and,  where  the 
purging  is  severe,  would,  by  lowering  the  density  of  the  blood, 
be  immediately  followed  by  an  increase  in  the  flow  from  the  bowels. 
When  the  stools  are  frequent  and  watery,  liquids  should  never  be 
given  in  larger  quantities  than  one  tablespoonful  at  a  time. 

Beyond  the  age  of  six  months,  a  little  beef  or  veal  tea  and  the 
^'■elk  of  one  egg  unboiled  may  be  added  to  the  diet.  The  egg  is 
best  digested  when  beaten  up  with  a  few  drops  of  brandy  and  a 
tablespoonful  of  cinnamon-water,  as  in  the  ordinary  egg-flip  of  the 
Pharmacopoeia.  As  with  younger  infants,  the  quantities  to  be 
given  at  one  time  must  depend  upon  the  strength  of  the  child  and 
the  state  of  his  bowels. 

If  the  child  be  over  twelve  months  old,  very  small  quantities  of 
farinaceous  food  may  sometimes  be  ventured  upon,  and  will  often 
agree.  The  best  form  in  which  this  can  be  given  is  the  boiled 
flour  prepared  as  described  on  page  46,  or  the  baked  flour  so 
strongly  recommended  by  Dr.  Underwood.^  Farinaceous  food 
can,  however,  only  be  allowed  in  very  small  quantities.  Its  value 
is  no  doubt  principally  owing  to  its  mechanical  action  in  separat- 
ing the  casein  of  the  milk  into  minute  portions,  so  that  the  masses 
of  curd  formed  are  small  and  easily  acted  upon.  One  teaspoonful 
to  the  four  ounces  of  milk  is  all  that  should  be  allowed.  More 
than  that  quantity  would  probably  be  undigested,  and  by  ferment- 
ing in  the  bowels  would  increase  the  irritation,  and  render  useless 
all  our  efforts  to  check  the  diarrhoea.  The  ordinary  farinaceous 
foods  should  not  be  given  to  children  under  twelve  months  old. 
Liebig's  food  for  infants  (Mellin's)  can,  however,  be  used  at  any  age. 
It  is,  perhaps,  next  to  breast-milk  itself  the  most  useful  food  in  all 
cases  of  deranged  digestion  in  children,  and  seldom  disagrees  even 
with  the  youngest  infants.     In  its  preparation  the  starch  of  the 

'  Dise§,ses  of  Children,  p.  244.  The  flour  is  slowly  baked  for  a  long  time  in  a 
small  covered  jar,  until  it  breaks  into  a  soft  grayish-colored  powder.  During  the 
progress  of  baking,  the  jar  must  be  occasionally  removed  from  the  oven,  and  the 
contents  stirred  up  from  the  bottom  and  sides  :  this  insures  its  being  equally 
baked  throughout,  and  prevents  the  formation  of  hard  lumps. 


78  CHRONIC    DIARRHCEA. 

wheaten  flour  which  forms  one  of  its  constituents  is  ah^eadj  con- 
verted in  great  measure  into  dextrine  and  grape-sugar,  so  that  the 
most  important  part  of  the  work  of  digestion  is  performed  before 
the  food  reaches  the  stomach. 

Whatever  be  the  diet  adopted,  our  object  is  to  keep  up  the 
nutrition  of  the  body  with  the  smallest  amount  of  irritation  to  the 
alimentary  canal,  and  the  food,  whatever  it  may  be,  which  will 
produce  this  result  is  the  food  best  suited  to  the  case.  Without 
attention  to  this  point  all  treatment  by  drugs  is  useless,  for  a  lump 
of  indigestible  food  will  neutralize  the  effect  of  the  most  powerful 
astringents.  The  successful  adjustment  of  the  diet,  an  adjustment 
in  which  the  quality  and  quantity  of  food  to  be  allowed  for  each 
meal  is  accurately  adapted  to  the  powers  and  requirements  of  the 
patient,  is  a  matter  which  can  be  properly  learned  only  by  experi- 
ence, and  which  often  makes  large  demands  upon  the  tact,  the 
ingenuity,  and  the  patience  of  the  medical  attendant.  This  experi- 
ence every  one  should  labor  to  acquire,  for  without  it  success  can 
seldom  be  attained  in  the  treatment  of  the  chronic  functional 
derangements  of  young  children. 

Although  milk  in  some  form  is  our  great  resource  in  the  cases 
here  treated  of,  as  affording  the  most  digestible  and  at  the  same 
time  the  most  nutritious  diet  we  have  at  our  disposal,  yet  it  is  not 
always  suitable.  It  is  not  so  very  uncommon  to  find  cases  where 
milk,  whether  diluted  with  lime-water,  or  thickened  with  isinglass 
or  with  Liebig's  food,  cannot  be  digested.  Here  the  passage  of 
four  or  five  large  pale  putty-like  stools  in  the  twenty-four  hours  is 
evidently  dependent  upon  the  milk  diet,  and  resists  all  treatment 
so  long  as  that  is  continued.  In  such  cases  the  milk  must  be 
replaced  either  wholly  or  partially  by  other  food. 

A  good  scale  of  diet  for  a  child  of  nine  months  old,  in  whom 
this  peculiarity  is  noticed,  is  the  following,^  consisting  of  five 
small  meals  in  twenty-four  hours. 

First  meal. — One  teaspoonful  of  Liebig's  food  for  iuftxnts  (Mel- 
lin's)  dissolved  in  four  ounces  of  milk  and  water :  equal  parts. 

Second  meal. — Four  ounces  of  beef-tea,  of  the  strength  of  a 
pound  of  fillet  of  beef  to  the  pint  of  water. 

Third  meal. — Four  ounces  of  fresh  whey  containing  a  teaspoon- 
ful of  cream. 

1  See  also  Diets  14,  15,  16,  aud  17,  Chap.  XI. 


DIET.  79 

Fourth  meal. — The  unboiled  yelk  of  one  egg,  plain,  or  beaten 
up  with  a  tablespoonful  of  cinnamon-water,  a  little  white  sugar, 
and  ten  drops  of  pale  brandy. 

Fifth  meal. — Same  as  the  first. 

In  this  dietary  the  first  and  the  fifth  meals  contain  a  small  quan- 
tity of  milk.  If  that  be  found  to  be  undigested,  the  food  may  be 
dissolved  in  barley-water,  alone  or  diluted  with  an  equal  quantity 
of  weak  veal  broth,  or  weak  veal  broth  alone  may  be  given.  In 
any  case  the  quantity  of  four  ounces  should  not  be  exceeded,  for 
it  is  wise,  especially  at  the  first,  to  be  sparing  rather  than  liberal  in 
regulating  the  allowance  of  food.  It  is  better  that  the  child  should 
be  hungry  than  overloaded;  and  so  long  as  the  stools  retain  their 
pasty  character  it  is  evident  that  the  food  taken  remains  in  great 
part  undigested.  In  these  cases,  and,  indeed,  in  all  cases  where  a 
special  diet  is  recommended  for  children,  a  dietary,  as  given  above, 
should  be  written  out  by  the  medical  attendant  for  the  benefit  of 
those  to  whose  care  the  child  is  intrusted.  Not  only  the  kind  of 
food,  but  the  quantity  to  be  given  at  each  meal,  and  even  the  hour 
at  which  the  meal  is  to  be  taken  should  be  duly  set  down,  so  that 
no  excuse  may  be  available  for  neglect  or  misapprehension.  It 
cannot  be  too  often  repeated  that  in  cases  such  as  these  it  is  upon 
the  judicious  arrangement  of  his  food  that  the  recovery  of  the 
child  depends,  and  that  where  the  diet  is  properly  selected,  the 
exact  medicine  to  be  ordered  becomes  a  matter  of  very  secondary 
importance. 

External  applications  are  excedingly  useful  in  this  disease,  for 
the  secretion  of  the  skin  is  usually  suppressed  at  an  early  period. 
The  hot  bath  may  be  used  at  first  every  night,  with  all  the  precau- 
tions already  enjoined  (see  page  26),  after  which  the  whole  body 
should  be  freely  anointed  with  warm  olive  oil,  and  the  child  be 
well  wrapped  up  in  flannel.  When  the  prostration  becomes 
marked  the  mustard  bath  may  be  ordered.  In  cases  where  ulcera- 
tion of  the  bowel  is  suspected,  and  it  is  thought  advisable  to  ap- 
ply local  counter-irritation,  a  poultice  consisting  of  equal  parts  of 
flour  of  mustard  and  linseed  meal  should  be  used.  This  should 
be  applied  at  some  distance  from,  and  not  directly  over,  the  seat  of 
disease — to  the  chest,  and  not  immediately  to  the  belly ;  and  its 
effect  should  be  carefully  watched  that  the  irritation  thus  excited 
may  be  kept  in  due  bounds.  If  the  child  is  very  weak,  the  mus- 
tard, after  remaining  on  a  few  minutes,  should  be  removed,  and  a 


80  CHRONIC    DIARRHCEA. 

hot  poultice  of  linseed-meal  should  be  applied  in  its  place.  When 
the  tenderness  of  the  abdomen  is  very  great,  it  is  advisable  to  keep 
the  whole  belly  constantly  covered  with  a  large  hot  linseed-meal 
poultice.  This  must  be  changed  frequently,  but  with  great  care 
that  the  child  be  not  chilled  in  the  process. 

Gentle  frictions  with  the  hand  over  the  abdomen  and  body  gen- 
erally are  useful  in  the  earlier  periods  of  the  disease,  and,  so  long 
as  there  is  no  tenderness  of  the  belly,  may  be  continued  with  ad- 
vantage. When  tenderness  is  present  they  should  only  be  used 
to  the  legs  and  feet. 

Internal  remedies.^ — If  the  patient  is  seen  at  the  first,  before 
the  diarrhoea  has  become  established,  and  when  there  is  nothing 
but  pallor,  languor,  gradual  loss  of  flesh,  griping  and  tenesmus, 
with  large,  pale,  sour-smelling  stools,  a  small  dose  of  powdered 
rhubarb,  with  carbonate  of  soda,  should  be  ordered,  and  then, 
when  the  bowels  are  relieved,  a  mixture  containing  tinct.  opii  with 
bicarbonate  of  soda  in  some  aromatic  water: — 

IJ,.    Tinct.  opii,  it^x  ; 

Sodge  bicarbonatis,  9ij  ; 

Syrupi  simplicis,  • 

Aquae  carui,  aa  §j.     M.     Ft.  mist,     ^j  ter  die. 

The  opium  at  once  renders  the  peristaltic  action  of  the  bowels 
more  regular,  and  the  stools  become  darker  and  less  offensive  in 
the  course  of  a  few  days.  This,  with  regulation  of  the  diet,  a 
flannel  bandage,  and  due  precautions  for  the  avoidance  of  cold,  is 
all  that  is  required. 

A  mixture  containing  tinct.  opii  and  castor  oil  is  also  very 
useful  if  the  tongue  is  furred  : — 

R..     Tinct.  opii,  Tr|^xvj  ; 
01.  ricini,  5jss ; 
Syrupi  zingib.,  §ss  ; 
Mucilag.  acacise,  §jss.     M.     3j  ter  die. 

But  it  should  not  be  used  if  the  tongue  is  clean,  and  must  not  be 
continued  longer  than  forty-eight  hours  if  no  benefit  be  found  to 
result  from  its  employment. 

Alteratives  are  in  these  cases  of  little  value,  for  it  is  no  use 
attempting  to  stimulate  the  functions  of  the  liver,  by  cholagogues. 
The  large  white  putty-like  stools  consist,  in  great  part,  of  undi- 

'  All  the  prescriptions  given  in  this  section  are  adapted  to  a  child  of  twelve 
months  old. 


ASTRINGENTS.  81 

gested  food,  and  we  sball  best  succeed  in  restoring  the  digestive 
power  by  antacids  and  aromatics,  as  directed  above,  and,  more 
than  all,  by  the  careful  adaptation  of  the  food,  both  in  quantity 
and  quality,  to  the  enfeebled  powers  of  the  child.  It  is  in  these 
cases  that  milk  is  seldom  well  borne,  except  in  very  small  doses 
well  diluted  with  lime-water,  and  is  often  necessary  to  replace  this 
by  otl\er  articles  of  diet,  as  already  described. 

AVhen  the  purging  sets  in,  if  the  stools  are  green,  and  slimy  or 
watery,  with  a  sour  smell,  it  is  best  to  begin  with  a  dose  of  bis- 
muth and  chalk : — 

I^.     Bismutlii  albi,  gr.  xvj  ; 
Pulv.  cret?e  aroinat.,  ^ij  ; 
Syrupi  simplicis, 
Mucilag.  tragacanth,  aa  §ss  ; 
Aqiiffi,  3j.     M.     Ft.  mistiira.     3j  sextis  lioris. 

If  there  is  much  tenesmus,  half  a  drop  of  tinct.  opii  may  be 
added  to  each  dose  of  the  mixture;  or  an  injection  containing  four 
or  five  drops  of  laudanum,  with  five  grains  of  bicarbonate  of 
potash,  to  half  an  ounce  of  thin  warm  starch,  may  be  thrown  up 
the  bowel.  Dr.  Evanson^  strongly  recommends  the  addition  of 
the  alkali,  which,  he  says,  greatly  increases  the  efficacy  of  the 
injection. 

So  long  as  the  stools  remain  sour-smelling,  antacids  should  be 
persisted  with.  An  aromatic  should  always  be  combined  with 
the  antacid.  "  This,"  says  Dr.  Underwood,'^  "  is  of  more  importance 
than  is  usually  apprehended.  I  have  known  a  careful  attention  to 
this  circumstance  alone  happily  suppress  complaints  in  the  bowels, 
which  had  long  continued  obstinate,  though,  in  other  respects, 
properly  treated."  In  these  cases,  too,  an  emetic  is  often  of  great 
service. 

If,  when  the  tongue  cleans,  the  diarrhoea  continues,  and  the 
stools  are  found  to  consist  of  dirty-brown  stinking  water,  astringents 
must  be  used.  Of  these,  the  best,  perhaps,  is  a  combination  of 
lead  and  of  opium  : — 

I^.     Plumbi  acetatis,  gr.  xij  ; 
Acidi  acetici,  dil.,  Tr\xx  ; 
Tiuct.  opii,  ^^.xii  ; 
Syrupi  simpl.,  3SS ; 
Aquae,  5Jss.     M.     5j  sexta  quaque  liora. 


'  Diseases  of  Children,  by  Maunsel  &  Evanson,  8vo.,  1847. 
2  Uuderwood,  p.  236. 

6 


82  CHEOXIC    DIARRHCEA. 

With  this  an  astringent  enema, 

^.     Ext.  Kramerise,  gr.  xv ; 

Mucilaginis  arnyli,  §iv.     M.     Ft.  enema, 

may  be  used  twice  a  day,  if  the  emaciation  is  great  and  the  diar- 
rhoea very  violent.  It  should  be  given  a  quarter  of  an  hour  after 
a  copious  injection  of  warm  water. 

It  is  well  to  vary  the  astringent  draught  every  two  or  three 
days,  and  the  following  mixtures  may  be  used  to  alternate  with  the 
lead : — 

I^.  Acidi  Gallici,  Qj  ; 

Acidi  sulphurici  aromat,  5s3  ; 

Tiuct.  opii,  lU^iij  ! 

Spirit,  jetheris,  gss; 

Syrupi,  §ss  ; 

Aquse,  ad  gij.     M.     5j  quarta  quaque  hor^. 
;^.  Tinct.  capsici,  ni.vj  ; 

Syrupi  simp.,  ^ss  ; 

Decoct,  hsematoxyli,  |jss.     M.     3j  quarta  quaque  horS,. 

This  combination  of  capsicum  with  the  astringent  is  often  ex- 
ceedingly useful  in  cases  where  there  is  no  tenderness  of  the  abdo- 
men or  straining.  If  these  symptoms  are  present  it  should  not  be 
used,  but  tinct.  catechu  may  be  substituted  for  the  capsicum  in  the 
proportion  of  five  drops  for  the  dose. 

Where  the  diarrhoea  is  very  obstinate,  nitrate  of  silver  is  strongly 
recommended  by  many  authors,  and  in  many  cases  is  very  suc- 
cessful in  checking  the  disease  after  everything  else  has  failed. 

R.  Argenti  nitratis  cryst.,  gr.  j  ; 
Acidi  nitrici  diluti,  'n\.v  ; 
Mucilaginis  acaciae, 
Syrupi,  aa  3 vj.     M.     5J  qi^arta- l^^iue  liora. 

This  mixture  is  especially  useful  in  cases  where  the  emaciation 
is  extreme,  and  the  stools  very  frequent,  non-fecal,  and  containing 
variously -colored  mucus  and  blood.  Mr.  Aiken  states  that  in  a 
case  in  which  he  tried  it,  "  the  first  dose  of  the  nitrate  seemed  to 
increase  the  discharge.  However,  in  about  six  hours  the  dejections 
improved ;  they  became  more  feculent,  and  every  symptom  under- 
went a  corresponding  improvement."^  When  the  prostration  is 
great,  with  aphthous  ulcerations  of  the  mouth,  the  nitrate  is  often 
of  much  service. 

'  Rankiug's  Abstract,  vol.  vi.  1S47. 


TREATMENT    BY    RAW    MEAT.  83 

It  is  in  cases  like  the  above  where  very  slimy  motions  are  passed 
with  much  straining  and  pain ;  and  where  the  lumps  of  coagulated 
bloody  mucus  found  in  the  stools  are  compared  by  the  attendants 
to  "  lumps  of  flesh,"  that  the  bichloride  of  mercury  treatment  is 
so  valuable.  One  teaspoonful  of  a  solution,  containing  a  grain  of 
the  salt  to  half  a  pint  of  water,  is  given  every  hour  or  two  hours. 
Very  speedy  success  often  follows  this  remedy. 

Injections  of  nitrate  of  silver  are  valuable  in  the  latter  stages, 
particularly  if  there  are  any  signs  of  ulceration  of  the  large  intes- 
tine. The  bowel  should  be  first  cleared  out  with  warm  water,  and 
then  an  enema,  containing  one  grain  of  the  nitrate  to  five  ounces 
of  water  should  be  administered.  Trousseau  recommends  that  in 
bad  cases,  it  should  be  repeated  twice  in  the  twenty-four  hours. 
These  astringent  enemata  must  not,  however,  be  continued  too  long 
they  should  be  suspended  every  two  or  three  days  in  order  to 
watch  the  effect,  and  in  the  interval  enemata  of  simple  starch  may 
be  used  as  recommended  by  MM.  Eillet  and  Barthez. 

All  this  time  the  diet  must  be  attended  to,  and  all  the  other  pre- 
cautions already  recommended  must  be  continued.  The  external 
applications,  as  before  described,  must  also  be  made  use  of,  em- 
ploying more  and  more  decided  counter-irritation  as  the  weakness 
of  the  child  increases,  and  his  prostration  becomes  more  marked. 

Stimulants  will  also  be  required  as  the  child  grows  weaker,  and 
must  be  given  pretty  freely  when  the  sinking  of  the  fontanelle 
and  the  other  symptoms  show  that  he  is  becoming  exhausted. 
Five  or  ten  drops  of  pale  brandy,  or  double  the  quantity  of  dry 
pale  sherry,  may  be  given  in  milk  three,  four,  six  times  a  day,  or 
even  every  hour,  as  required.  Good  beef  gravy,  free  from  fat,  is 
also  useful  at  these  times. 

Not  seldom,  in  spite  of  all  our  efforts,  the  child  goes  on  from 
bad  to  worse.  The  diarrhoea  resists  all  treatment,  and  continjies 
obstinate  whatever  be  the  measures  adopted.  In  these  cases  the 
treatment  by  raw  meat  becomes  a  valuable  resource.  All  food  must 
be  stopped,  and  the  child  must  be  nourished  in  the  following  way: 
A  piece  of  raw  mutton  or  rump-steak,  free  from  gristle  or  fat,  is 
finely  minced,  and  is  pounded  in  a  mortar  till  it  is  converted  into 
a  pulp.  The  pulp  is  then  strained  through  a  fine  sieve  or  a  piece 
of  muslin,  to  remove  the  bloodvessels  and  cellular  tissue.  Of  the 
meat  so  prepared,  a  teaspoonful  is  given  at  regular  intervals  four 
times  in   the  day,  and  every  day  the  quantity  administered  is 


81  CHRONIC    DIARRHOEA. 

gradually  increased,  until  half  a  pound  is  taken  each  day  in 
divided  doses.  During  this  treatment  no  other  food  of  any  hind 
must  he  allowed,  and  no  fluid  but  thin  barley-water,  or  a  drink 
made  by  mixing  the  unboiled  whites  of  three  eggs  in  a  pint  of 
water,  sweetening  it,  and  flavoring  with  a  little  orange-flower 
water.  This  diet  usually  causes  the  motions  to  have  an  intensely 
offensive  smell ;  but  this  is  of  no  consequence,  and  the  parents 
should  be  warned  of  its  liability  to  occur.  The  patients  them- 
selves often  like  this  food,  and  take  it  eagerly.  If,  however,  as 
may  happen,  they  show  any  repugnance  to  it,  the  pulp  may  be 
sweetened  with  white  sugar,  or  a  little  confection  of  roses  may  be 
added  to  make  it  more  palatable,  or  it  may  be  given  in  a  small 
quantity  of  veal  broth.  As  medicine,  we  must  give  at  the  same 
time  the  bismuth  and  chalk  mixture,  with  the  addition  of  one 
drop  of  tinct.  opii  to  each  dose.  This  mode  of  treatment  is  strongly 
recommended  by  Professor  Trousseau,  from  whom  the  above 
method  of  preparation  is  derived.  There  can  be  no  doubt  about 
the  value  of  this  remedy.  Under  its  influence  the  stools  become 
less  frequent  and  less  liquid,  and  although  they  remain  for  a  time 
horribly  fetid,  yet  they  gradually  assume  more  and  more  the 
character  of  healthy  evacuations,  while  the  other  symptoms  un- 
dergo a  like  amendment.  For  the  first  day  or  two  the  meat  will 
be  found  in  the  motions  almost  unchanged,  except  for  decomposi- 
tion, the  dejections  consisting  of  colorless  fibriue,  with  a  little 
cellular  tissue  and  mucus ;  but  by  perseverance  we  find  that  it 
begins  gradually  to  be  digested,  and  less  of  it  appears  every  day 
in  the  stools. 

When  from  this  or  other  treatment  the  diarrhoea  has  been  ar- 
rested, and  the  stools  have  become  more  healthy-looking,  a  tonic 
should  be  given,  and  the  one  best  adapted  to  continue  the  im- 
provement is  the  solution  of  the  pernitrate  of  iron,  which  has 
besides  a  beneficial  influence  upon  the  alimentary  canal.  It  is 
best  given  with  dilute  nitric  acid  : — ■ 

K..  Liq.  ferri  pernitratis,  ^ss  ; 
Acidi  nitrici  diluti,  5ss  ; 
Syrupi  ziiigib.,  §j  ; 
Aquaui  Anethi,  ad  |iij.     M.     ^ij  sextS,  quaque  hora. 

Other  tonics  may  afterwards  be  given,  as  the  decoction  of  bark 
with  syrup,  the  citrate  of  iron  and  quinine,  cod-liver  oil,  &c.  If 
the  oil  be  given,  its  effects  must  be  carefully  watched.     It  is  best 


DANGER    OF    RICKETS.  85 

to  begin  with  a  small  dose,  as  ten  drops,  in  a  teaspoonful  of  milk 
three  times  in  the  day  ;  but  if  there  be  any  smells  of  the  oil  in  the 
stools,  even  this  small  quantity  must  be  diminished.  The  consti- 
pation, which  usually  succeeds  to  the  diarrhoea,  should  not  be 
lightly  interfered  with.  If  two  or  three  days  have  passed  without 
any  action  of  the  bowels,  a  very  small  dose — about  twenty  drops — ■ 
of  castor  oil  may  be  administered,  and  may  be  repeated,  if  neces- 
sary, after  four  or  five  hours. 

As  so  much  harm  is  often  done  in  these  cases  of  chronic  diar- 
rhoea by  little  indiscretions,  it  is  of  extreme  importance  that  we 
should  not  allow  improvement  to  make  us  relax  in  our  attention 
or  diminish  our  precautions.  It  is  a  good  rule  in  all  cases  where 
the  child  is  getting  better  to  act  as  if  he  were  getting  worse,  to 
redouble  our  vigilance  rather  than  to  relax  in  it,  for  at  any  time  a 
chill  or  a  fragment  of  indigestible  food  may  undo  all  that  has  been 
done,  and  throw  the  child  back  into  a  state  from  which  it  has 
required  perhaps  weeks  of  unremitting  care  to  deliver  him. 

After  the  cessation  of  the  diarrhoea  the  child  must  not,  however, 
be  kept  too  low.  As  his  digestive  power  increases,  his  diet  should 
be  improved  in  proportion.  This  is  very  important,  as  rickets  is 
not  an  uncommon  result  of  the  impairment  of  nutrition  produced 
by  the  disease,  and  is  therefore  favored  by  anything  which  tends 
to  prolong  the  weakly  condition  of  the  infant. 


CHAPTER    III. 

CHRONIC   VOMITING. 

Chronic  Vomiting,  its  Symptoms  and  Tkeatment. — Frequency  of  slight  attacks  of 
gastric  disturbance — Such  attacks  easily  remedied — Chronic  vomiting  non- 
febrile — Symptoms,  those  of  gradual  interference  with  nutrition,  ending  in 
exhaustion — Spurious  hydrocephalus. 

Causes.  Diagnosis. — From  tubercular  meningitis — Diagnosis  of  spurious  hydro- 
cephalus. 

Treatment. — Attention  to  diet — Return  to  breast — Substitute  for  wet-nurse — 
Warmth — External  applications — Baths — Medicines — Bismuth  and  magnesia 
— Calomel — Dilute  hydrocyanic  acid — Enemata — Emetics — Rules  for  giving 
these — Stimulants. 

Slight  attacks  of  vomiting,  lasting  for  twenty-four  bonrs,  or 
even  for  several  days,  are  not  at  all  uncommon  in  infants  even 
while  at  tbe  breast.  The  matters  ejected  consist  of  the  food,  of 
stringy  mucus,  and  of  bile  ;  at  the  same  time  there  is  some  beat  of 
skin,  thirst,  loaded  tongue,  and  constipation  or  diarrhoea.  These 
attacks,  unless  aggravated  by  much  meddling,  always  end  favor- 
ably. The  only  treatment  required  is  an  emetic  of  ipecacuanha 
wine  to  relieve  the  stomach,  followed  by  a  gentle  purge,  and  by 
careful  regulation  of  the  diet.  Sometimes  it  is  necessary  to  forbid 
even  the  breast-milk  for  a  time,  and  to  restrict  the  infant  to  cold 
thin  barley-water  given  with  a  teaspoon. 

These  attacks  are  of  little  consequence.  The  child  may  get  a 
little  flabby  and  pale,  but  when  convalescent  a  week  of  ordinary 
feeding  restores  bim  to  his  former  state  of  health.  Vomiting  may, 
however,  become  chronic  and  persistent.  It  is  then  much  more 
serious,  and  produces  very  great  wasting  and  prostration. 

Symptoms. — There  is  no  fever.  Tbe  child  vomits  at  irregular 
intervals,  tbrowing  up  the  milk  curdled  and  sour-smelling,  and,  at 
the  first,  tinged  green  or  yellow  from  bile.  The  bile,  however, 
soon  disappears  from  the  vomited  matters,  and  clear  fluid,  like 
water,  is  ejected,  alone  or  mixed  with  the  food.  On  pressure  of 
the  epigastrium  the  child  writhes  as  if  in  pain.     The  belly  is  full, 


SYMPTOMS.  87 

often  tympanitic,  and  gurgles  wlien  pressed  upon.  Eructations 
occur  of  fetid,  sour  gas,  and  the  bowels  are  obstinately  confined. 
An  eruption  of  stropliulus  often  covers  the  body  and  arms.  The 
child  gets  thinner  and  paler,  and  is  very  fretful.  The  fontanelle 
becomes  depressed.  Some  diarrhoea  may  at  first  alternate  with 
the  constipation,  but  after  a  few  days  the  bowels  become  again 
confined,  and  the  motions,  when  they  occur,  consist  of  rough,  hard 
lumps,  very  light-colored,  evacuated  with  great  straining.  The 
lumps  may  be  covered  with  tough  mucus.  The  tongue  is  coated 
with  a  thick  layer  of  dirty -yellow  fur :  it  is  not  very  moist,  and 
dull-red  papillae  of  medium  size  are  seen  peering  through  the  fur, 
here  and  there,  on  the  dorsum  of  the  tongue.  The  breath  smells 
sour.  The  lips  are  dry  and  red.  A  furrow  passes  down  from  each 
side  of  the  nose  to  encircle  the  corner  of  the  mouth,  so  that  the 
lips  seem  to  project.  The  mouth  seems  clammy  and  parched,  and 
the  child  takes  the  breast  eagerly  to  relieve  this  parched  feeling 
by  the  flow  of  milk,  but  rejects  what  he  has  swallowed  very  shortly 
afterwards. 

After  the  child  has  remained  in  this  state  for  a  considerable 
time,  often  with  occasional  intervals  of  improvement  for  several 
months,  the  vomiting  becomes  more  frequent.  It  occurs  not  only 
after  taking  food,  but  also  in  the  intervals  of  feeding,  and  seems 
to  be  excited  by  the  slightest  movement,  or  by  a  touch,  so  that 
the  mere  act  of  wiping  the  mouth  may  bring  on  a  fresh  attack  of 
retching.  The  milk  is  thrown  up  uncurdled.  Emaciation  then 
goes  on  rapidly.  The  skin  is  dry  and  harsh,  and  hangs  loose  and 
flaccid :  the  eyes  get  hollow ;  the  nose  sharpened ;  the  cheeks 
sunken ;  and  the  belly  retracted.  He  lies  with  the  knees  drawn 
up  on  to  the  abdomen,  and,  when  they  are  straightened  out,  returns 
them  as  soon  as  possible  to  their  former  position.  Occasionally  he 
moves  his  legs  uneasily,  as  if  in  pain.  He  is  intensely  fretful, 
breaking  out  into  sudden  cries,  or,  as  he  becomes  weaker,  into  a 
low,  pitiful  wail,  which  is  even  more  distressing  to  hear,  and  never 
seems  to  sleep,  night  or  day.  The  tongue  is  dry,  and  is  still  furred, 
so  that  it  has  a  rough,  granular  appearance.  At  length  the  child 
is  reduced  to  a  state  of  extreme  emaciation.  The  surface  of  the 
body  is  pale  and  cold ;  the  hands  and  feet  become  more  or  less 
purple ;  and  the  temperature,  as  shown  by  a  thermometer  placed 
in  the  rectum,  may  sink  as  low  as  97°  Fahr. ;  vomiting  occurs  at 
the  slightest  movement ;  the  child  lies  dozing  or  in  a  state  of  semi- 


88  CHRONIC    VOMITING. 

stupor,  with  eyes  half  closed,  and  the  only  sign  of  vitality  is  respi- 
ration. When  thrush  appears  upon  the  inside  of  the  cheeks  and 
lips,  it  is  a  sign  that  the  end  is  approaching,  and  he  gradually 
sinks  and  dies,  the  constipation  persisting  to  the  last. 

Towards  the  end  of  the  disease,  symptoms  which  have  been 
described  as  "spurious  hydrocephalus"  are  often  noticed.  Dr. 
Gooch,^  in  his  valuable  paper  on  this  disorder,  says,  "It  is  chiefly 
indicated  by  heaviness  of  head  and  drowsiness;  the  age  of  the 
little  patients  whom  I  have  seen  in  this  state  has  been  from  a  few 
months  to  two  or  three  years ;  they  have  been  rather  small  of  their 
age,  and  of  delicate  health,  or  they  have  been  exposed  to  debili- 
tating causes.  The  physician  finds  the  child  lying  on  its  nurse's 
lap,  unable  or  unwilling  to  raise  its  head,  half  asleep,  one  moment 
opening  its  eyes,  and  the  next  closing  them  again  with  a  remark- 
able expression  of  languor.  The  tongue  is  sliglitly  white,  the  skin 
is  not  hot,  at  times  the  nurse  remarks  that  it  is  colder  than  natural ; 
in  some  cases  there  is  at  times  a  slight  and  transient  flush :  the 
bowels  I  have  always  seen  already  disturbed  by  purgatives,  so 
that  I  can  scarcely  say  what  they  are  when  left  to  themselves : 
thus  the  state  I  am  describing  is  marked  by  heaviness  of  the  head 
and  drowsiness,  without  any  signs  of  pain,  great  languor,  and  a 
total  absence  of  all  active  febrile  symptoms." 

The  symptoms  thus  described  are  not  peculiar  to  chronic  vomit- 
ing, although  they  are  especially  apt  to  occur  with  that  disease. 
They  may  be  found  in  all  cases  where  great  exhaustion  is  induced 
from  whatever  cause,  and  are  therefore  not  uncommon  in  chronic 
diarrhoea.  In  all  these  cases  the  fontanelle  is  deeply  depressed, 
showing  deficiency  in  the  amount  of  bood  circulating  through  the 
brain;  the  pupils  are  often  dilated  and  immovable,  and  there  may 
be  coma,  with  stertorous  breathing. 

In  cases  of  recovery  the  vomiting  becomes  less  frequent,  and  gra- 
dually ceases,  although  for  some  time  it  is  liable  to  recur  if  much 
food  be  taken  at  once.  The  constipation,  however,  remains  obsti- 
nate for  some  time  after  the  cessation  of  the  vomiting.  The  child 
then  begins  to  regain  flesh,  and  often  becomes  exceedingly  fat. 

Causes. — Most  of  the  cases  of  this  disorder  which  have  come 
under  the  author's  notice  have  b'cen  in  infants  of  a  few  months,  old, 

>  On  Symptoms  in  Children  erroneously  attributed  to  Congestion  of  the  Brain. 
New  Sydenham  Society,  1859. 


CAUSES  —  DIAGNOSIS.  89 

and  have  usuall}'  resulted  from  premature  weaning,  the  child  being 
taken  from  the  breast  and  fed  upon  farinaceous  or  other  articles  of 
diet  which  he  is  unable  to  digest.  It  is  not  an  uncommon  com- 
plaint in  infants  whose  mothers  have  obtained  the  situation  of  wet- 
uurse,  and  who  are  in  consequence  left  to  the  care  of  ignorant  and 
often  careless  attendants. 

The  crowding  of  children  together  in  close  nurseries,  or,  amongst 
the  poor,  the  stifling  atmosphere  of  the  one  room  in  which  a  whole 
family  is  so  often  lodged,  is  another  common  cause  of  the  disorder. 

These  causes  have  already  been  fully  discussed  under  the  head 
of  chronic  diarrhoea. 

Severe  operations  upon  the  child,  such  as  that  for  stone  in  the 
bladder,  are  often  followed  by  an  acid  dyspepsia,  which  may  lapse 
into  obstinate  vomiting ;  a  chronic  catarrh  of  the  stomach  and 
bowels  being  set  up,  which  may  lead  to  death  after  the  more  im- 
mediate effects  of  the  operation  have  been  recovered  from.  Any 
cause,  in  fact,  which  lowers  the  easily  depressed  general  strength 
will  reduce  also  the  digestive  power,  and  thus  predispose  to  this 
complaint. 

Diagnosis. — The  combination  of  obstinate  vomiting,  with  consti- 
pation, might  give  rise  to  the  suspicion  of  tubercular  meningitis, 
but  the  two  diseases  are  readily  distinguished.  The  age  of  the 
child,  tubercular  meningitis  being  exceedingly  rare  under  twelve 
months;  the  temperature  of  the  body,  which  is  depressed  instead 
of  being  elevated ;  the  sunken  fontanelle ;  the  rapid,  feeble,  but 
regular  pulse ;  the  state  of  the  belly,  swollen  rather  than  retracted ; 
all  tend  to  exclude  the  latter  disease. 

Towards  the  end  of  the  complaint,  when  the  symptoms  of  spu- 
rious hydrocephalus  are  noticed,  the  history  of  the  case,  the  cold- 
ness of  the  skin,  the  depressed  fontanelle,  and  the  state  of  the  pulse, 
are  all  adverse  to  the  idea  of  cerebral  lesion,  and  point  to  the 
true  nature  of  the  complication,  viz.,  a  deficiency  of  blood  circu- 
latino-  throutrh  the  brain. 

Ireaiment. — ^Our  first  care  must  be  to  attend  to  the  proper  feed- 
ing of  the  child.  If  he  has  been  prematurely  weaned  a  wet  nurse 
should  be  provided,  and  great  care  must  be  taken  that  the  person 
selected  should  produce  milk  of  a  quality  suited  to  the  infant,  for 
the  milk  of  different  nurses  differs  very  much  in  quality.  If, 
therefore,  a  return  to  the  breast  is  not  followed  by  the  expected 
improvement,  the  nurse  should  be  changed,  or  measures  should  be 


90  CHRONIC    VOMITING. 

taken  to  render  the  secretion  better  adapted  to  the  infant.  If,  on 
examination,  the  milk  appears  to  be  deficient  in  fat  globules,  a 
more  nourishing  diet  should  be  recommended ;  if,  on  the  other 
hand,  it  be  too  rich,  the  amount  of  meat  must  be  restricted,  and 
she  should  take  fresh  vegetables,  with  an  occasional  saline  ape- 
rient. If  these  measures  do  not  succeed,  there  should  be  no  hesi- 
tation in  changing  the  nurse  if  another  can  be  procured. 

When  the  disease  has  continued  a  long  time,  and  the  child  is 
much  reduced,  the  mere  act  of  sucking  appears  often  to  excite 
retching.  In  such  cases  the  nurse's  milk  may  be  given  with  a  tea- 
spoon. In  all  cases  the  child  should  take  the  breast  at  regular 
intervals,  and  should  not  be  allowed  to  suck  too  long  at  one  time; 
the  amount  of  nourishment  he  is  permitted  to  swallow  being  regu- 
lated, on  each  occasion,  by  the  degree  of  irritability  of  the  stom- 
ach, and  by  the  result  which  has  followed  the  previous  meal.  If 
that  has  been  rejected,  the  quantity  of  milk  allowed  to  be  drawn 
at  the  next  suckling  must  be  diminished.  In  many  cases  a  tea- 
spoonful  of  the  breat-milk  given  at  intervals  of  ten  minutes,  or 
even  longer,  is  all  that  can  be  retained.  Often,  however,  on  the 
other  hand,  the  stomach,  which  has  rejected  all  other  food,  at  once 
recognizes  the  change  of  diet,  and  the  vomiting  is  speedily  arrested 
by  a  return  to  the  breast. 

If  a  wet-nurse  cannot  be  obtained,  ass's  milk,  or  equal  parts  of 
cow's  milk  and  lime-water  must  be  given  instead,  beginning  with 
very  small  quantities  at  the  first.  These  can  be  gradually  increased 
according  to  the  readiness  with  which  they  are  retained.  In  some 
cases,  where  milk  alone,  or  with  lime-water,  is  persistently  vom- 
ited, Liebig's  food  prepared  with  milk  and  water  (a  teaspoonful  of 
the  food  to  four  ounces  of  fluid),  is  kept  down :  in  others,  fresh 
whey  with  cream  prepared  as  recommended  on  p.  48,  is  successful.' 
In  these  cases  of  obstinate  vomiting  it  is  an  important  point  to 
remember  that  the  food,  whatever  it  may  be,  should  be  given  either 
hot  or  cold;  but  not  tepid,  as  liquid  food  given  in  a  lukewarm  state 
would  be  apt  to  favor  a  return  of  the  vomiting. 

The  infant  should  be  warmly  clothed,  with  a  flannel  bandage 
round  the  belly,  and,  while  the  vomiting  is  urgent,  should  be  kept 
in  a  room  comfortably  warm,  but  not  too  hot.  Fresh  air  should 
be  freely  admitted,  and  at  night,  if  there  is  no  fire,  a  lamp  should 

'  See  also  Chap.  XI. 


IMPORTANCE    OF    WARMTH.  91 

be  placed  in  the  chimney.  Great  cleanliness  should  be  maintained ; 
clothes  and  linen  moistened  with  the  vomited  matters  should  not 
be  allowed  to  remain  in  contact  with  the  child's  body,  but  should 
be  at  once  removed  from  the  room.  The  whole  body  should  be 
well  sponged  with  warm  water  twice  a  day. 

It  is  extremely  important  to  keep  the  feet  warm.  Thick  woollen 
socks  should  be  supplied,  and  the  feet  should  be  occasionally  well 
rubbed  with  the  hand  alone,  or  with  a  liniment  composed  of  equal 
parts  of  linimentum  camphorge  co.  and  linimentum  saponis.  If 
they  still  continue  cold,  they  may  be  placed  in  a  mustard  foot-bath, 
with  water  sufficient  to  cover  the  lower  extremities  as  high  as  the 
knees.  Warm  applications  to  the  epigastrium  and  belly  are  of 
great  service;  hot  linseed-meal  poultices,  made  more  stimulating 
by  the  addition  of  a  little  mustard,  should  be  applied  to  the  pit  of 
the  stomach,  and  at  times  frictions  may  be  used  over  the  belly 
with  the  same  embrocation  as  has  been  directed  for  the  feet.  If 
there  is  great  prostration,  the  child  may  be  placed  for  a  few  min- 
utes in  a  bath  of  the  temperature  of  90°  Fahr.,  or  the  mustard 
bath  may  be  used.  All  these  applications  are  useful,  not  only  as 
counter-irritants,  but  also  as  tending  to  promote  the  free  action  of 
the  skin.  With  the  same  object,  inunctions  of  olive  oil  may  be 
made  use  of,  the  oil,  well  warmed,  being  smeared  over  the  whole 
body  once,  twice,  or  oftener  in  the  day,  as  already  recommended 
(see  Introduction).  By  this  means,  also,  a  considerable  quantity  of 
nourishment  can  be  introduced  into  the  system;  it  is  a  measure 
which  should  never  be  neglected  when  the  vomiting  is  obstinate. 

"With  regard  to  the  medicines^  to  be  employed : — if  the  child  is 
seen  early,  before  the  strength  is  much  reduced,  and  there  is  a  sour 
smell  from  the  breath,  with  a  thickly  furred  tongue,  an  emetic 
should  be  at  once  administered.  A  teaspoonful  of  ipecacuanha 
wine  is  the  form  in  which  this  can  be  given.  Afterwards,  when 
the  stomach  has  been  emptied  of  the  acrid  secretions  and  mucus, 
a  mixture  containing  bismuth  with  magnesia  should  be  ordered : — 

^.  Bismuthi  alb.,  gr.  xvj  ; 
Magnes.  carb.,  ^ij  ; 
Tinct.  myrrhae,  gss ; 
Syrupi, 

Mucilag.  tragacanth.,  aa  533  ; 
Aquam,  ad  §ij.     M.     5J  ^^^  ^'^^' 

'  All  the  prescriptions  given  in  this  chapter  are  adapted  to  an  infant  of  six 
months  old. 


92  CHRONIC    VOMITING. 

The  bowels,  which  are  usually  confined,  should  be  excited  to  act 
by  an  enema.  For  a  child  of  six  months  old,  a  small  teacupful  of 
■warm  barley-water,  containing  a  tablespoonful  of  olive  oil,  may  be 
injected  into  the  bowel,  or  ten  grains  of  powdered  socotrine  aloes 
dissolved  in  the  same  quantity  of  barley-water,  or  of  boiled  milk, 
may  be  used.  The  action  of  the  bowels  must  be  maintained 
either  by  enemata,  by  suppositories  of  castile  soap,  or  by  purga- 
tives given  by  the  mouth.  The  latter  method  is  inapplicable  as 
long  as  tbe  vomiting  continues  incessant ;  but  when  this  becomes 
less  frequent,  a  grain  of  calomel  may  be  placed  on  the  tongue,  or 
a  mixture  containing  ten  to  twenty  drops  of  tinct.  aloes  may 
be  given  two  or  three  times  in  the  day.  The  tincture  of  aloes  is 
strongly  recommended  by  Dr.  Davies^  in  these  cases,  combined 
with  a  few  drops  of  sal  volatile. 

If  the  vomiting  continues  unabated,  small  quantities  of  calomel 
may  be  given ;  a  sixth  of  a  grain  being  laid  on  the  tongue  ever}' 
four  hours.  The  effect  of  this  medicine  is  sometimes  very  striking; 
as  the  nurses  say,  "  it  acts  like  a  charm."  Should  this,  however, 
not  succeed,  small  doses  of  dilute  hydrocyanic  acid  may  be  given 
with  nitre,  as  in  the  following  mixture.  Nitre  is  a  powerful  seda- 
tive to  the  stomach : — 

I^.  Acidi  hydrocyanici  diluti,  11^ vj  ; 
Potas.  nitratis,  5j  ! 
Syrupi,  5SS  ; 
Aquffi,  §js3.     M.     5J  ter  die. 

And  if,  in  spite  of  this,  the  irritability  of  the  stomach  remains 
undiminished,  half  a  drop  of  tinct.  opii  may  be  added  to  each  dose 
of  the  mixture. 

One-drop  doses  of  vinum  ipecacuanhse,  or  of  liq.  arsenicalis,  will 
often  succeed  in  arresting  the  vomiting  even  in  very  obstinate 
cases,  and  after  all  other  treatment  has  proved  ineflfectual.  Thus, 
one  dro]5  of  ipecacuanha  wine  may  be  given  in  a  teaspoonful  of 
water  every  two  or  three  hours,  or  even  every  hour,  according  to 
the  urgency  of  the  case. 

The  following  case  illustrates  the  influence  of  this  remedy,  com- 
bined with  altered  diet,  in  checking  vomiting  of  long  standing: — 

"Jessie  W — ,  aged  six  months,  has  been  brought  up  by  hand 
from  her  birth.     Has  been  gradually  wasting   for  four  months. 

'  See  Underwood's  Treatise  on  Diseases  of  Children,  p.  227. 


INTERNAL    REMEDIES.  93 

She  vomits  all  food,  although  different  diets  have  been  adopted, 
and  is  now  excessively  emaciated.  Feet  always  cold.  Belly 
rather  full  and  tense.  Fontanelle  large  and  rather  elevated,  but 
not  tense.  Veins  of  side  of  head  rather  full.  Complexion  earthy. 
Breath  smells  sour.  Tongue  rather  dry  and  granular  looking  from 
projecting  papillte.     Motions  yellowish  and  hard. 

"  Ordered.  Diet :  Equal  parts  of  new  milk  and  lime-water,  to 
be  given  in  small  quantities  at  regular  intervals. 

I^.  Vin.  ipecaciiauhse,  TTj^xvj  ; 
Aq.  meuth.  pip., 
AqucB,  aa  §j     M.     gj  tertia  liorS,. 

"  A  teaspoonful  of  cod-liver  oil  to  be  rubbed  into  belly  every 
night. 

"A  flannel  bandage  to  be  applied  to  the  belly,  and  the  feet  to 
be  kept  perfectly  warm. 

"  By  these  means  the  vomiting  was  stopped  at  once.  After  a 
few  days,  the  complexion  cleared,  the  earthy  tint  disappearing,  and 
the  child  began  to  regain  flesh.  The  mixture  was  then  changed 
to— 

^.  Ferri  et  ammoii.  citratis,  gss  ; 
Potass,  bicarb.,  5Jss  ; 
Tr.  opii,  H\,viij  ; 
Aquani,  ad  3ij.     M.     3J  ter  die." 

If  the  vinum  ipecacuanhas  do  not  succeed,  one-drop  doses  of  liq. 
arsenicalis  may  be  tried,  given  in  a  teaspoonful  of  water  three 
times  a  day. 

The  same  remedy  should  not  be  continued  too  long  at  a  time,  if 
no  improvement  be  seen  to  follow  its  employment.  Our  greatest 
trust  should  be  placed  in  warmth,  in  stimulation  of  the  suri'ace, 
and  in  promoting  free  action  of  the  bowels.  When  the  fontanelle 
becomes  much  depressed,  stimulants  are  always  indicated ;  and  of 
these  pale  brandy,  given  in  five-drop  doses,  in  a  teaspoonful  of 
breast-milk,  or  of  the  milk  and  lime-water,  seems  to  answer  the 
best.  When  the  prostration  is  great  the  stimulant  may  be  re- 
peated every  hour,  or  even  oftener. 

With  regard  to  a  repetition  of  the  emetic,  a  few  words  may  be 
said.  An  emetic  is  only  required  when  there  is  reason  to  suspect 
the  presence  of  acrid  secretions  in  the  stomach.  If,  however,  the 
tongue  is  tolerably  clean,  and  there  is  no  sour  smell  from  the 
breath,  an  emetic  is  no  longer  indicated,  and  its  employment  would 


94  CHRONIC    VOMITIXG, 

only  increase  the  prostration.  Yoraiting  is  sometimes  kept  up  by 
debility  of  the  stomach,  and  this  would  be  only  increased  by  the 
exhibition  of  nauseating  remedies.  When  the  prostration,  as  shown 
by  the  condition  of  the  fontanelle,  is  very  great,  much  caution 
should  be  exercised  in  giving  emetics,  as  fatal  syncope  is  some- 
times seen  in  such  cases  to  follow  their  employment,  and  if  the 
fontanelle  is  deeply  depressed  they  should  on  no  account  be  made 
use  of. 

If  the  vomiting  continue  after  the  tongue  has  become  clean, 
stimulants  should  at  once  be  given,  and  the  following  are  very 
useful : — 

;^.  Sp.  ammon.  aromat., 

Sp.  chloroformi,  aa  gss  ; 

Ext.  glycyrrhizae,  9ij  ; 

Decocti  cinchonse,  5ij.     M.     3j  ter  die. 

IJl.  Acidi  nitrici  diluti, 

Sp.  aether,  nitrosi,  aa  3ss  ; 

Tinet.  myrrhse,  3j  ; 

Syrapi  ziugib.,  §3S  ; 

Aquam  carui,  ad  ^ij.     M.     gj  quartl.  quaque  borS,. 

Either  of  these  may  be  used,  and  should  be  continued  for  some 
time  after  the  vomiting  has  ceased. 

As  the  child  improves  he  may  be  taken  out  of  doors,  if  the 
weather  is  not  too  cold,'  for  a  free  supply  of  fresh  air  is  a  most  im- 
portant agent  in  the  treatment  of  this  as  of  all  the  other  chronic 
diseases  of  children. 

The  symptoms  which  have  been  described  as  "spurious  hydro- 
cephalus" show  a  very  dangerous  degree  of  prostration,  and  must 
be  treated  with  stimulants. 


CHAPTER    IV. 

RICKETS. 

Rickets. — Preliminary  symptoms  those  of  general  malnutrition — Symptoms  of 
commencement — Deformities  of  bones — Enlargement  of  ends  of  bones — Soften- 
ing— Thickening  of  flat  bones — Mechanical  deformities — Bones  of  head  and 
face — Distinction  between  the  rickety  and  hydrocephalic  skull — Cranio-tabes 
— Dentition — Spine — Thorax — Deformities  of  long  bones  and  of  pelvis — Ar- 
rest of  growth  of  bones — Articulations — Relaxation  of  ligaments — Other 
symptoms — Enlargement  of  liver  and  spleen — Intellect — Complications — 
Catarrh  and  bronchitis — Diarrhoea — Laryngismus  stridulus — Convulsions — 
Chronic  hydrocephalus — Death  from  intensity  of  general  disease. 

Patliology. — Rickets  a  general  disease — Anatomical  characters  of  bony  changes — 
KoUiker's  views — Virchow's  views — Analysis  of  rickety  bone — Emphysema 
and  collapse — Alterations  in  lymphatic  glands — In  spleen — Liver — In  other 
organs — Urine. 

Diagnosis.     Prognosis. — Importance  of  complications. 

Causes. — Rickets  not  a  diathetic  disease — Bad  feeding  and  hygiene — Connection 
between  rickets  and  syphilis. 

Prevention.  Treatment. — Diet — Dry  bracing  air — Attention  to  digestive  organs — 
Tonics — Value  of  mechanical  supports — Treatment  of  complications — Catarrh 
Diarrhoea — Bronchitis — Laryngismus  stridulus. 

Rickets,  although  one  of  the  most  preventable  of  children's 
diseases,  is  yet  one  of  the  most  common.  It  begins  insidiously, 
presenting  at  first  merely  the  ordinary  symptoms  of  defective 
assimilations,  and  attention  is  often  not  attracted  to  it  until  the 
characteristic  changes  occur  in  the  bones  which  place  the  existence 
of  the  disease  beyond  a  doubt. 

Many  of  the  symptoms  described  under  the  head  of  simple 
atrophy,  constitute  a  preliminary  stage  of  rickets.  They  are  not, 
as  has  been  said,  characteristic  of  this  special  disease,  but  merely 
mark  the  process  of  gradual  reduction  of  strength,  and  of  inter- 
ference with  the  assimilative  functions,  which  must  take  place  to 
a  certain  degree  before  the  disease  can  be  established.  This  pre- 
liminary stage  is  not,  however,  always  present.  Rickets  is  the 
result   of  malnutrition :   any  disease,  therefore,  which   seriously 


96  RICKETS. 

interferes  with  the  assimilative  power,  and  causes  sufficient  im- 
pairment of  the  general  strength,  may  be  followed  directly  by  the 
disorder  under  consideration,  without  any  intervening  stage.  Re- 
duce the  strength  to  a  given  point,  and  rickets  begins.  Prolong 
this  state  of  debility  sufficiently,  and  the  characteristic  changes 
resulting  from  the  disease  manifest  themselves.  Any  cause,  there- 
fore, which  will  reduce  the  strength  to  this  point  lays  the  founda- 
tion of  rickets. 

Symptoms. — The  commencement  of  the  disease  is  indicated  by 
the  following  symptoms  : — 

Profuse  sweating  of  the  head,  or  of  the  head,  neck,  and  upper 
part  of  the  chest.  The  perspiration  is  extreme :  it  will  be  seen 
standing  in  large  drops  upon  the  forehead,  and  often  runs  down 
the  face.  There  is  increased  moisture  of  the  parts  usually  in  the 
day  as  well  as  at  night;  but  if  the  child  falls  asleep,  it  is  instantly 
augmented,  and  at  night  is  sufficient  to  make  the  pillow  wet. 
AVhen  awake,  the  slightest  exertion  or  elevation  of  the  temperature 
excites  it  at  once.  At  the  same  time,  the  superficial  veins  of  the 
forehead  are  large  and  full,  the  jugular  veins  are  distended,  and 
the  carotid  arteries  may  sometimes  be  felt  strongly  pulsating. 
The  irritation  excited  by  this  constant  perspiration  will  often  give 
rise  to  a  crop  of  miliaria  about  the  temples,  the  upper  part  of  the 
forehead  close  to  the  roots  of  the  hair,  and  at  the  back  of  the  neck. 
While  the  head  and  neck  are  thus  batned  in  perspiration  the 
abdomen  and  lower  limbs  are  usually  dry  and  hot. 

Another  characteristic  symptom  is  the  desire  of  the  child  to  lie 
cool  at  night.  In  the  coldest  weather  he  will  kick  off  the  bed- 
clothes, or  throw  his  naked  legs  outside  the  counterpane.  The 
mother  often  notices  this  as  one  of  the  earliest  symptoms,  and 
will  say  that  she  has  been  obliged  to  wrap  her  child  up  in  flannel 
to  prevent  his  catching  cold,  as  he  will  not  remain  covered  by  the 
bed-clothes. 

These  two  symptoms  precede  the  deformities  of  the  osseous 
structure ;  but  there  is  another  symptom  which  appears  later,  and 
marks  the  commencement  of  morbid  changes  in  tiie  bones.  It  is, 
however,  frequently  absent  in  mild  cases.  This  symptom  is  gene- 
ral tenderness.  The  child  at  first  shows  signs  of  uneasiness  when 
danced  up  and  down  in  the  arms  of  his  mother.  As  the  tender- 
ness increases,  he  becomes  peevish  at  being  touched,  and  prefers 
sitting  quietly  in  his  little  chair,  or  lying  down  in  his  cot,  for  all 


GENERAL    TENDERNESS.  97 

voluntary  movements  increase  the  pain.  Eventually,  as  the  dis- 
ease progresses,  he  lies  motionless  in  his  bed,  and  cries  violently 
even  at  the  approach  of  persons  who  have  been  accustomed  to 
play  with  him.  This  conduct,  so  different  from  that  of  a  healthy 
child,  who  delights  in  all  movement,  is  highly  characteristic. 

These  special  symptoms  are  accompanied  by  all  the  other  phe- 
nomena which  preceded  the  commencement  of  the  disease.  The 
bowels  remain  confined,  or  are  more  or  less  capricious,  a  day  or 
two  of  relaxation  being  followed  by  an  equal  period  of  constipa- 
tion. More  often,  however,  there  are  three  or  four  evacuations  in 
the  course  of  the  twenty-four  hours,  accompanied  by  considerable 
straining.  The  stools  consist  of  whitish,  curdy-looking  matter, 
mixed  with  mucus,  and  are  extremely  offensive.  The  food  taken 
seems  to  pass  almost  unchanged  through  the  alimentary  canal, 
being,  no  doubt,  forced  too  rapidly  along  from  abnormal  exalta- 
tion of  the  peristaltic  action  of  the  bowels,  so  that  sufficient  time  is 
not  allowed  for  digestion.  The  urine  becomes  more  abundant, 
and  deposits  a  calcareous  sediment,  or  abounds  in  phosphates. 
There  is  usually  some  thirst;  but  the  appetite  is  often  voracious, 
so  that  the  child  very  shortly  after  a  meal  will  show  a  disposition 
to  eat  again.  This  is  what  we  constantly  meet  with  in  cases  of 
dyspepsia  in  the  adult,  where  the  peristaltic  action  of  the  intestines 
is  unnaturally  brisk.  The  child  soon  loses  his  power  of  walking, 
and  sits,  or  lies  about.  He  becomes  dull  and  languid,  and  neglects 
his  playthings.  There  is  usually  some  emaciation;  but  if  the 
symptoms  are  not  severe  at  the  first,  he  may  be  plump  in  appear- 
ance, although  his  flesh  feels  soft  and  flabby.  In  the  daytime  he 
is  drowsy,  but  at  night  is  restless,  turning  his  head  uneasily  from 
side  to  side  on  the  pillow. 

The  symptoms  proper  to  rickets  very  seldom  appear  before  the 
fourth  month,  and  not  commonly  before  the  seventh  or  eighth. 
From  his  own  experience  the  author  would  say  that  the  disease 
manifests  itself  most  frequently  between  the  seventh  and  eighteenth 
months,  less  frequently  between  the  eighteenth  month  and  the  end 
of  the  second  year,  and  rarely  after  the  end  of  the  second  year. 
Still,  we  may  find  it  commencing  at  a  later  period ;  and  Sir  Wil- 
liam Jenner  mentions  the  case  of  a  girl,  aged  nine  years,  who-  was 
then  only  just  beginning  to  suffer. 

The  deformities  of  the  bones  usually  begin  at  the  time  when 
general  tenderness  is  first  complained  of  The  osseous  system  is 
7 


98  RICKETS. 

attacked  as  a  whole,  and  therefore  all  the  bones  in  the  body  seem 
to  suffer  at  the  same  time.  Sir  William  Jenner,^  in  his  Lectures 
on  Eickets,  thus  enumerates  the  most  constant  changes  which  are 
found  to  occur  in  them. 

"Enlargement  of  the  ends  of  the  long  bones,  of  the  parts  where 
the  bone  and  cartilage  are  in  contact,  i.  e.,  where  the  cartilage  is 
preparing  for  ossification,  and  where  ossification  is  advancing  in 
the  cartilage. 

"  Softening  of  all  the  bones. 

"  Thickening  of  the  flat  bones,  e.  g.,  the  bones  of  the  skull ;  the 
scapula ;  the  pelvis. 

"  Deformities  which  follow  from  mechanical  causes  acting  on  the 
softened  bones,  e.  g.,  the  deformities  of  the  thorax,  pelvis,  spine, 
long  bones." 

In  a  well-marked  case  of  the  disease  we  find  all  these  changes  ; 
but  very  commonly  many  of  them  are  absent.  Even  when  present 
thev  do  not  always  occur  to  an  equal  degree  :  sometimes  the  soften- 
ing of  the  bones  is  more  marked  than  their  enlargement;  at  others 
the  enlargement  is  out  of  proportion  to  the  softening,  M.  Gueriu- 
has  stated — he  has  even  laid  it  down  as  an  absolute  rule — that  the 
deformities  of  the  bones  begin  from  below  upwards,  that  the  tibiae 
become  affected  before  the  thigh  bones,  the  thigh  bones  before  the 
pelvis,  and  so  on  to  the  arms  and  head.  This,  however,  is  not 
correct.  In  some  cases  we  certainly  find  the  legs  and  thighs  bowed 
earlier  than  the  other  parts,  but  it  is  in  children  who  have  walked, 
or  can  still  walk ;  and  in  them  the  weight  of  the  body  determines 
the  deformities  of  the  lower  limbs  before  the  pressure  upon  the 
other  bones  has  been  sufficient  to  make  them  crooked.  Besides, 
if  a  very  heavy  child  be  put  on  his  legs  at  too  early  an  age,  the 
tibia3  may  bend  a  little,  although  there  is  no  reason  to  suspect  the 
child  of  being  the  subject  of  rickets. 

The  changes  in  the  different  bones  will  now  be  described. 

Bones  of  the  head  and  face. — The  skull  is  larger  than  it  ought  to 
be,  and  is  of  a  peculiar  shape.  Its  antero-posterior  diameter  is 
increased  ;  the  fontanelle  remains  open — often  widely  open — long 
after  the  end  of  the  second  year,  the  ordinary  period  of  its  closing ; 
the  thickening  of  the  bones  is  most  marked  at  the  centres  of  the 

'  Medical  Times  and  Gazette,  March  17,  1860. 
2  Memoiie  sur  le  Rachitis.     Paris,  1857. 


MORBID    CHANGES    IX    BONE.  99 

parietal  bones,  the  bosses  of  the  temporal  bones,  and  at  tlie  edges 
of  the  bones  outside  the  sutures,  so  that  the  situation  of  the  sutures 
is  indicated  by  deep  furrows ;  the  vertex  is  flattened,  and  the 
sutures  are  expanded  or  remain  open.  The  forehead  is  high, 
square,  and  projecting,  and  is  out  of  proportion  to  the  face.  This 
disproportion  is  exaggerated  by  the  arrest  of  growth  of  the  bones 
of  the  face,  particularly  of  the  bones  of  the  upper  jaw  and  the 
malar  bones;  therefore,  while  the  forehead  is  larger,  the  face  is 
smaller  than  natural.  The  projection  of  the  forehead  is  due  partly 
to  thickening  of  the  frontal  bone,  partly  to  expansion  of  the  frontal 
and  ethmoidal  sinuses,  but  principally,  according  to  Sir  W.  Jenner, 
to  disease  of  the  cerebrum.  The  under  jaw  appears  rather  elon- 
gated. 

It  is  important  to  distinguish  between  the  rickety  enlargement 
of  the  skull,  and  the  expansion  which  takes  place  in  hydrocephalus. 
In  hydrocephalus  there  is  greater  disproportion  between  the  skull 
and  the  face ;  the  enlargement  is  more  globular  and  regular,  the 
antero-posterior  diameter  not  being  greater  than  the  lateral ;  the 
bones  of  the  skull  do  not  give  to  the  finger  the  sensation  of  being 
thickened ;  the  fontanelle  is  more  open,  and  if  the  accumulation  of 
fluid  be  great,  the  bones  at  the  sutures  are  more  widely  separated; 
the  sutures  themselves  are  not  bounded  by  a  ridge  of  thickened 
bone.  The  fontanelle  in  hydrocephalus  is  elevated ;  in  rickets  it 
is  depressed,  partly  on  account  of  the  debility,  partly  on  account 
of  thickening  of  the  bones  which  form  its  boundaries.  In  rickets 
we  find  other  well-marked  symptoms  showing  the  nature  of  the 
disease.  The  two  diseases  are,  however,  occasionally  combined, 
and  the  diagnosis  may  be  thus  rendered  difficult ;  but  so  long  as 
the  fontanelle  remains  depressed,  we  may  positively  exclude 
hydrocephalus. 

A  curious  condition  of  the  skull,  known  as  cranio-tabes,  is  some- 
times found.  This  was  first  detected  by  Elsasser,^  and  has  been 
carefully  described  by  Dr.  Alfred  VogeV  of  Munich.  On  using 
gentle  pressure  with  the  tips  of  the  fingers  on  all  the  posterior  sur- 
face of  the  head,  spots  can  be  sometimes  detected  where  the  bone 
is  thinned.  The  bone  at  these  spots  is  elastic,  feels  '"  like  cartridge 
paper,"  and  presents  a  concavity,  or  depression,  which  varies  in 

1  Der  weiclie  Hinterkopf.     Stuttgart,  1843. 

2  Lelirbucli  der  Kinderkranklieiteu,  von  Dr.  Alfred  Vogel.     Erlaugeu,  1863. 


100  RICKETS. 

size  according  to  the  extent  of  the  thinning.  The  usual  size  of 
these  depressions  varies  from  a  linseed  to  a  bean  ;  but,  according 
to  Dr.  Vogel,  one  whose  size  does  not  exceed  a  line  in  diameter 
can  be  detected  by  the  practised  finger. 

These  local  losses  of  substance  are  confined  to  the  occipital  bone, 
of  which  any  par.t  may  be  affected  except  the  protuberances.  The 
frontal  and  parietal  bones  are,  however,  greatly  thickened,  often  to 
double  their  natural  depth. 

This  cranio-tabes  is  said  by  Dr.  Yogel  to  be  one  of  the  earliest 
signs  of  rickets,  preceding  the  beading  of  the  ribs.  It  is  seldom 
found  before  the  third  month,  or  after  the  second  year. 

The  progress  of  dentition  is  arrested.  If  the  disease  makes  its 
appearance  before  any  of  the  teeth  are  cut,  their  evolution  may  be . 
almost  indefinitely  postponed.  If  some  teeth  have  already  ap- 
peared, the  further  progress  of  dentition  is  interrupted.  This  influ- 
ence over  the  teeth  is  peculiar  to  rickets.  In  no  other  disease,  in 
which  general  nutrition  is  affected,  do  we  find  any  interference 
with  the  natural  course  of  dentition.  In  a  child  greatly  wasted 
by  chronic  diarrhoea,  or  improper  food,  the  development  of  the 
teeth  does  not  seem  to  be  hindered  by  causes  which  exercise  so 
powerful  an  influence  upon  his  general  health ;  and  in  tubercu- 
losis and  congenital  syphilis  the  teeth  are  usually  cut  early. 

Teeth  which  have  already  appeared  speedily  become  black, 
decay,  and  drop  early  from  their  sockets.  This  is  due,  according 
to  Dr.  Vogel,  to  insufiicient  development  of  the  dental  enamel.  It 
is  not  at  all  uncommon  to  see  a  rickety  child  of  eighteen  months 
or  two  years  old  with  very  few  teeth  as  yet  in  his  head,  and  those 
few  black  and  carious. 

In  some  rare  cases,  however,  we  find  dentition  unaffected,  and 
even  particularly  forward,  although  the  other  symptoms  of  rickets 
are  well  marked.  Thus,  "  Herbert  K.  cut  his  first  tooth  when  five 
months  old,  and  at  the  age  of  one  year  and  nine  months  dentition 
was  completed.  He  could  not  stand  until  his  seventeenth  month, 
and,  when  a  year  and  a  half  old,  could  not  walk  without  assistance. 
It  was  only  just  before  cutting  his  last  tooth  that  he  was  able  to 
walk  alone.  When  seen,  he  was  aged  two  years  and  nine  months, 
a  pale  and  rather  weakly-looking  boy  ;  wrists  large  ;  tibia3  bowed; 
the  teeth,  however,  were  perfect  and  particularly  sound." 

Tlie  spine  is  bent,  but  the  curvature  is  only  strongly  marked 
when  the  muscular  debility  is  very  decided.     The  direction  of  the 


DEFORMITIES    OF    THE    THORAX.  101 

curve  varies  according  to  whether  the  child  can  or  cannot  walk. 
If  the  child  cannot  walk,  the  cervical  anterior  curve  is  increased, 
and  there  is  a  posterior  curve  reaching  from  the  first  dorsal  to  the 
last  lumbar  vertebra.  This  is  an  exaggeration  of  the  ordinary 
curve  which  exists  when  a  child  sits  unsupported  on  the  arm  of 
his  nurse.  If  the  muscular  debility  is  very  great,  the  curvature 
may  be  so  pronounced  as  to  be  mistaken  for  angular  curvature. 
It  is,  however,  readily  distinguished  by  holding  a  child  up,  sup- 
porting him  with  the  hands  under  the  arms  :  the  weight  of  the 
body  will  then  usually  straighten  the  spine  at  once,  particularly  if 
gentle  pressure  is  at  the  same  time  made  on  the  projecting  part. 

If  the  child  is  able  to  walk,  the  dorsal  spine  is  curved  back- 
wards, the  lumbar  forward. 

As  a  consequence  of  the  cervical  curve,  and  the  accompanying 
weakness  of  the  muscles,  the  head  is  no  longer  efficiently  sup- 
ported; it  therefore  falls  back,  and  the  child  usually  favors  this 
falling  back,  in  order  that  he  may  see  what  is  going  on  around 
him. 

Lateral  curvatures  are  occasionally  seen,  but  they  are  far  less 
common  than  the  antero-posterior.  Their  direction  is  determined 
by  the  position  assumed  by  the  child.  If  it  is  carried  constantly 
on  the  left  arm,  there  is  lateral  curvature,  with  convexity  to  the 
left;  if  on  the  right  arm,  the  convexity  is  to  the  right. 

The  thorax  is  curiously  deformed.  Flattened  behind,  projecting 
sharply  in  front,  it  presents  an  appearance  which  Glisson^  compares 
to  the  prow  of  a  ship,  and  which  forms  the  condition  commonly 
known  as  "pigeon-breasted."  The  ribs,  as  they  leave  the  spine, 
are  directed  at  first  almost  horizontally  outwards,  then  bend 
sharply  at  an  acute  angle  at  the  junction  of  the  dorsal  and  lateral 
regions,  and  from  that  point  pass  forwards  and  inwards  to  unite 
with  their  cartilages.  The  cartilages  curve  outwards  before  turning 
in  to  their  articulations  with  the  sternum,  so  that  the  breast-bone 
is  forced  forwards,  and  the  antero-posterior  diameter  of  the  chest 
is  unnaturally  increased.  The  lateral  diameter  is  greatest  opposite 
the  acute  angle  formed  by  the  ribs;  least,  at  the  points  of  junction 
of  the  ribs  with  their  cartilages.  This  curving  inwards  of  the  ribs, 
and  outwards  of  their  cartilages,  forms  a  groove  on  the  antero-lateral 

'  De  Rachitide,  sive  Morbo  Puerili.  F.  Glissoii,  edit,  tertia.  Lugdanum  Bata- 
vorum,  1671. 


102  EICKETS. 

face  of  the  chest,  which  reaches  from  the  ninth  or  tenth  rib  below, 
to  the  third,  second,  or  even  first  rib  above,  and  the  groove  is 
deepest  just  outside  the  nodules  formed  by  the  enlarged  ends  of 
the  ribs.  The  groove  varies  on  the  two  sides  in  length  and  in 
depth,  for  the  liver  and  the  heart  support  to  a  certain  extent  the 
ribs  under  which  they  lie.  Thus  the  groove  reaches  downwards 
to  a  less  distance  on  the  right  side  than  on  the  left,  on  account  of 
the  liver ;  and  at  the  level  of  the  fourth  and  fifth  ribs  it  is  shallower 
on  the  left  side  than  on  the  right,  on  account  of  the  heart.  The 
enlargement  of  the  ends  of  the  ribs  gives  a  peculiar  appearance  to 
the  surface  of  the  chest ;  a  line  of  nodules  is  seen,  looking  like  a 
row  of  large  beads  under  the  skin,  lying  along  the  inner  side  of 
the  groove.  Below  the  sixth  rib  the  chest  widens,  as  the  walls  are 
forced  outwards  by  the  underlying  liver,  stomach,  and  spleen. 

If  we  strip  a  rickety  child  and  watch  his  breathing,  we  see  that 
in  inspiration  there  is  sinking  in  of  the  chest  walls.  The  lateral 
depressions  deepen;  the  sternum  moves  forwards;  the  abdomen 
expands ;  and  a  deep  horizontal  groove  furrows  the  surface,  divid- 
ing the  chest  from  the  belly,  and  marking  the  upper  borders  of 
the  abdominal  viscera.  This  recession  of  the  chest  walls  shows 
the  mechanism  by  which  the  deformity  is  produced.  In  the  healthy 
subject,  when  the  diaphragm  contracts,  and  the  ribs  are  elevated 
in  the  act  of  inspiration,  air  rushes  in  through  the  glottis  to  expand 
the  lungs,  and  to  enable  them  to  follow  and  remain  in  contact  with 
the  expanding  chest  walls.  The  atmospheric  pressure  is,  therefore, 
overcome  by  the  power  of  the  osseous  and  muscular  walls,  aided 
by  the  pressure  of  the  inspired  air.  In  the  rickety  child,  however, 
one  of  these  agents  is  comparatively  powerless.  The  softened  ribs 
can  afford  little  assistance  to  the  air  within  the  chest  in  counter- 
balancing the  pressure  outside :  they  therefore  sink  in  at  their  least 
supported  parts,  and  produce  the  lateral  furrows  which  have  been 
described,  while  at  the  same  time  the  sternum  is  carried  forwards 
in  proportion  to  the  recession  of  the  ribs. 

Sir  William  Jenner  denies  the  truth  of  Eokitansky's  statement 
that  want  of  power  in  the  inspiratory  muscles  is  the  cause  of  the 
deformity.  Repeated  dissections  have  conclusively  proved  to  him 
that  the  points  of  insertion  of  the  muscles  of  respiration,  and  the 
points  of  recession  of  the  chest  walls,  have  no  correspondence 
whatever.  He  also  denies  the  influence  of  the  diaphragm  in  pro- 
ducing the  circular  or  horizontal  depression  described  above.   That 


CAUSE    OF    THE    DISTORTION    OF    LONG    BONES.       103 

depression  corresponds,  not  to  the  points  of  attachn^.ent  of  the 
diaphragm,  but  to  the  upper  borders  of  the  liver,  stomach,  and 
spleen,  which  thus  support  the  parietes,  and  prevent  their  sinking 
in  under  the  pressure  of  the  air.  A  similar  cause  produces  an 
apparent  bulging  of  the  pra3Cordial  region  during  inspiration,  for 
the  heart  supports  the  ribs  behind  which  it  lies,  and  prevents  their 
receding  to  the  same  extent  as  the  walls  around. 

The  thoracic  deformity  is  sometimes  seen  to  lessen  at  the  time 
the  legs  are  bending.  This  seems  to  be  due  to  the  disease  having 
diminished,  and  the  muscular  power  having  increased  sufficiently 
to  allow  of  the  child  walking  before  the  bones  of  the  legs  are 
strong  enough  to  bear  the  weight  of  the  body. 

The  c?«u/c7e  is  also  distorted.  There  are  two  great  curves:  the 
principal  one,  forwards  and  rather  upwards,  is  situated  just  outside 
the  points  of  attachment  of  the  sterno-mastoid  and  pectoral  muscles. 
The  second,  backwards,  is  about  half  an  inch  from  the  scapular 
articulation. 

The  hnnierus  is  sometimes  curved  just  where  the  deltoid  muscle 
is  inserted. 

The  radius  and  ulna  are  curved  outwards,  and  also  twisted. 

These  deformities  are  ascribed  by  most  authors  to  muscular 
action,  aided  by  the  weight  of  the  limb.  Sir  "W,  Jenner,  how- 
ever, excludes  altogether  the  first-mentioned  cause  from  any 
share  in  the  production  of  these  distortions.  They  are  due,  he 
says,  to  the  habit  practised  by  all  rickety  children,  owing  to  their 
deficiency  in  muscular  power,  of  supporting  the  body,  while  sitting, 
upon  the'open  hands  placed  upon  the  bed  or  floor.  The  weight  of 
the  trunk  is  therefore,  in  a  great  measure,  thrown  upon  the  arms, 
and  we  see  in  consequence  the  deformities  of  the  clavicle,  the 
humerus,  and  the  bones  of  the  forearm,  which  have  been  described. 
The  curvature  of  the  humerus  is  also  aided  by  the  weight  of  the 
forearm  and  hand  when  the  limb  is  raised  by  the  action  of  the 
deltoid.  The  weight  of  the  arm  on  the  humeral  end  of  the  clavi- 
cle— the  sternal  end  being  supported  by  its  muscles  and  ligaments — 
will  also  assist  in  producing  the  disfigurement  of  the  collar-bone. 

The  scapula  is  very  much  thickened,  and  is  said  occasionally  to 
be  so  deformed  as  to  interfere  with  free  motion  of  the  shoulder- 
joint. 

^he  pelvis  varies  greatly  in  shape,  but  is  more  often  triangular 
than  oval.     Pressure  may  be  brought  to  bear  upon  it  in  many  dif- 


10-i  RICKETS. 

ferent  directions :  thus  it  is  pressed  upon  from  above  by  the  weight 
of  the  spine  and  the  contents  of  the  abdomen  ;  from  below  by  the 
heads  of  the  thigh  bones.  The  exact  direction  in  which  these 
compressing  forces  will  act  varies,  firstly,  according  to  the  position 
of  the  child — lying,  sitting,  standing,  or  walking;  and  secondly, 
according  to  the  age  at  which  the  disease  comes  on,  and  therefore 
according  to  the  degree  of  ossification  of  the  bones,  for  the  carti- 
lages are  less  yielding  than  the  bones  themselves.  The  distortion 
of  the  pelvis  thus  produced  is  often  very  remarkable.  In  a  child 
of  four  and  a-half  years  old.Mn  whom  lithotomy  was  performed 
by  Sir  Henry  Thompson,  at  University  College  Hospital,  the 
outlet  of  the  pelvis  was  so  contracted  as  barely  to  allow  a  stone, 
measuring  IJ  in.  in  length,  I  in.  in  breadth,  and  f  in.  in  thickness, 
to  pass  through  in  its  long  axis.  The  child  died  shortly  after  the 
operation  from  peritonitis,  and  on  examination  of  the  pelvis,  the 
brim  was  found  to  be  exceedingly  contracted.  Its  shape  was 
obliquely  caudate :  the  sacral  promontory  was  distant  |  in.  from 
the  left  pubic  ramus,  |  in.  from  the  pubic  ramus  of  the  right  side, 
and  I  in.  from  the  symphysis  of  the  pubes. 

Beside  the  softening  of  the  bones  there  is,  however,  another 
cause  which  assists  to  produce  a  diminished  capacity  of  the  pelvis, 
as  will  be  afterwards  explained. 

The  f emu 7'  is  curved  forwards  if  the  child  cannot  walk.  If  he 
can  walk  it  is  curved  forwards  and  outwards,  being  an  exaggera- 
tion of  the  natural  curve.  Sometimes  the  head  of  the  femur  is 
seen  bent  at  an  acute  or  an  obtuse  angle  to  the  shaft. 

The  tibia,  before  the  child  walks,  is  curved  outwards,  and  the 
knees  are  then  seen,  as  the  child  is  held  upright,  to  be  widely 
separated  from  one  another.  After  the  child  walks,  the  weight  of 
the  body  determines  the  bending.  In  these  cases  the  distortion  is 
seen  principally  at  the  lower  third,  and  the  curve  is  very  abrupt, 
seeming  to  project  over  the  foot;  or  the  bend  may  be  outwards, 
projecting  over  the  outer  ankle. 

In  these  cases,  also,  the  deformity  can  be  explained  otherwise 
than  by  the  influence  of  muscular  action.  While  the  child  sits  in 
his  mother's  lap  the  weight  of  the  legs  and  feet,  pulling  upon  the 
lower  end  of  the  femur,  produces  the  forward  curvature  of  that 

'  An  account  of  this  case  will  be  found  in  the  Medical  Times  and  Gazette  for 
December  5,  18tj3. 


INTENSITY    OF    THE    DISEASE.  105 

l3one.  As  the  child  sits  cross-legged  on  the  floor  or  bed  the  pressure 
on  the  external  malleolus  causes  the  normal  curve  of  the  tibia  to 
be  exaggerated. 

The  changes  in  the  bones  thus  described  may  take  place  to  any 
degree.  Some  may  be  more  marked,  others  less,  according  to  the 
severity  of  the  disease,  the  age  of  the  child,  and  the  time  at  which 
treatment  is  commenced.  If  the  premonitory  symptoms  have  been 
very  mild,  tenderness  may  be  altogether  absent,  and  the  afifection 
of  the  bones  be  limited — at  any  rate,  at  first — to  beading  of  the 
ribs,  enlargement  of  the  wrists  and  ankles,  retardation  of  dentition, 
and  abnormal  openness  of  the  fontanelle.  The  child,  if  able  to 
walk,  is  still  pretty  strong  on  his  legs ;  he  is  lively,  often  plump, 
and  does  not  appear  to  suffer  much  from  the  disease  under  which 
he  is  laboring.  If  treatment  is  at  once  had  recourse  to,  nutrition 
is  restored,  growth  and  development  recommence,  and  health 
quickly  returns.  On  the  other  hand,  if  the  general  symptoms 
which  precede  the  attack  have  been  very  severe,  ^.  e.,  if  the  de- 
bility resulting  from  the  deficient  nutrition  is  very  great,  the  ten- 
derness of  the  bones  is  a  well-marked  symptom,  the  softening  will 
usually  precede,  and  be  out  of  proportion  to,  the  enlargement  of 
the  ends  of  the  bones,  and  all  the  distortions  which  have  been 
described  will  be  the  result. 

Again,  the  older  the  child  when  rickets  first  appears  the  less 
likely  is  he  to  be  affected  early  by  softening  of  the  bones,  while  if 
the  child  is  very  young,  the  bones  usually  soften  very  quickly. 
This,  however,  is  perhaps  merely  a  consequence  of  what  has  just 
been  stated,  for  the  younger  the  child  the  more  likely  is  his  sys- 
tem to  be  profoundly  affected  by  malnutrition,  and  therefore  the 
more  severe  will  be  the  consequences  of  that  malnutrition. 

Besides  the  softening  of  the  bones,  and  the  deformities  which 
result  from  it,  there  is  another  effect  of  the  disease  which  is  not 
less  remarkable.  This  effect  is  the  arrest  of  growth  of  the  bones.^ 
The  arrest  is  seen  not  only  while  the  disease  is  still  in  progress, 
but  it  even  continues  after  apparent  restoration  to  health.  In  a 
rickety  skeleton  all  the  bones  are  found  to  be  stunted  in  growth, 
and  this  combined  with  the  bending  of  the  lower  limbs,  which 
must  necessarily  detract  from  the  height  of  the  individual,  is  the 

'  See  two  papers,  by  Mr.  Shaw,  published  iu  the  Transactions  of  the  Mecl.-Chir. 
Society,  vols.  xvii.  and  xxvi. 


106  ^  RICKETS. 

cause  of  the  short  stature  of  persons  who,  when  young,  have  been 
subject  to  this  disease.  The  arrest  of  growth  affects  some  bones 
more  than  others,  being  principally  noticeable  in  the  bones  of  the 
face,  of  the  lower  limbs,  and  of  the  pelvis.  As  it  affects  the  pel- 
vis the  want  of  growth  is  very  important  from  its  influence  upon 
child-bearing  in  after  life.  In  the  child  the  size  of  the  pelvis  and 
lower  limbs  is  small  in  proportion  to  the  rest  of  the  body ;  in  the 
adult  female  it  has  so  increased  as  to  be  relatively  larger  than  the 
other  parts  of  the  bony  framework.  If  then  the  growth  and  deve- 
lopment of  the  pelvis  are  arrested,  its  brim  and  outlet  do  not 
undergo  the  usual  expansion,  but  remain  small  and  contracted, 
retaining  the  characters  of  the  infantile  pelvis.  The  obstacle  to 
the  passage  of  the  foetal  head,  under  such  circumstances,  becomes 
extreme,  especially  if  conjoined  with  deformities  produced  by 
softened  bone,  and  usually  requires  craniotomy  or  embryotomy 
before  the  child  can  be  extracted.  This  condition  of  the  pelvis  may 
also  interfere  with  operations  upon  the  child,  as  in  the  case  of  litho- 
tomy already  referred  to.  According  to  Mr.  Shaw,  there  is  a  cor- 
respondence between  the  degree  to  which  the  pelvis  suffers  from 
this  arrest  of  growth  and  development,  and  the  degree  to  which 
the  lower  limbs  suffer  from  the  same  causes";  we  can  therefore  by 
observing  the  amount  of  stunting  of  the  lower  limbs  make  some 
estimate  of  the  extent  to  which  the  pelvis  is  likely  to  be  modified 
in  size  and  capacity. 

The  articulations. — As  the  ends  of  the  long  bones  are  enlarged 
the  joints  into  which  these  bones  enter  must  necessarily  be  en- 
larged also.  They  have  therefore  a  knotted,  bulbous  look,  an 
appearance  which  is  aggravated  by  the  atrophy  of  the  muscles  of 
the  limb.  In  addition  to  this  the  ligaments  which  hold  the  bones 
together  are  relaxed  :  the  joints  are  therefore  loose  and  unsteady, 
and  can  be  moved  freely  in  directions  which,  in  a  healthy  state, 
would  be  impossible.  This  looseness  and  mobility  of  the  joints 
forms  alone  a  great  impediment  to  walking,  even  should  the 
bones  themselves  be  healthy,  and  in  fact  the  relaxation  of  the  liga- 
ments does  not  always  bear  a  due  proportion  to  the  osseous 
changes.  It  is  often  an  early  symptom,  and  we  frequently  see  it 
carried  to  a  high  degree  in  cases  where  the  disease  in  the  bones  is 
as  yet  comparatively  trifling.  In  these  cases,  if  we  hold  the  child 
upright,  so  that  the  weight  of  the  body  rests  upon  the  feet,  we  see 
that  each  lower  limb  forms  an  obtuse  am^le  at  the  knee ;  the  knees 


MOBILITY    OF    THE    JOINTS.  107 

touch;  the  legs  are  directed  outwards;  and  the  foot  is  more  or  less 
everted  from  relaxation  of  the  ligaments  of  the  ankle.  In  children 
in  whom  the  disease  appears  at,  or  after,  the  end  of  the  second 
year,  this  weakness  in  the  joints  is  a  very  prominent  symptom, 
and  is  often  found  where  the  limbs  are  perfectly  straight  and  well 
formed. 

The  following  case  illustrates  this  peculiarity.  It  is  interesting 
besides  as  an  example  of  rickets  occurring  as  a  sequel  of  inherited 
syphilis. 

"Frederick  W.,  aged  two  years  "and  a  half.  Nineteen  teeth. 
Began  to  snuffle  soon  after  birth.  Was  vaccinated  at  the  age  of 
thirteen  weeks,  and  an  eruption  then  appeared  all  over  body 
except  chest;  spots  also  were  seen  surrounding  the  anus.  This 
has  continued  off  and  on  till  within  the  last  three  months.  At 
seven  months  two  lower  incisors  appeared.  Could  not  walk  before 
the  age  of  thirteen  months  and  a  half.  Child  very  auEemic  look- 
ing ;  striking  pallor  of  face :  very  light  flaxen  hair.  Tongue 
covered  with  a  thinnish  coating  of  white  fur ;  red,  round,  medium- 
sized  papillae  scattered  all  over  dorsum.  Bowels  usually  confined ; 
motions  offensive.  Strains  often  at  stool.  Does  not  sweat  about 
head,  but  used  to  do  so  till  very  lately.  Throws  off  bed-clothes  at 
night.  Does  not  care  about  playing;  prefers  to  sit  quietly.  Head 
large :  antero-posterior  diameter  very  long.  Fontanelle  the  size  of 
a  threepenny  bit.  When  stripped  the  body  generally  is  seen  to  be 
exceedingly  pale.  Child  in  tolerably  good  condition :  totters  as 
he  wallvs.  ISTo  enlargement  of  ends  of  bones  ;  limbs  straight ;  joints 
relaxed,  knees  loose,  and  ankles  yield  under  the  weight  of  the 
body.  Ends  of  ribs  not  visible  to  the  eye,  but  can  be  felt  to  be 
nodular.  Chest  not  deformed.  No  spots  on  skin,  but  a  scar  of 
old  ulcer  by  the  side  of  anus.     Spleen  not  enlarged." 

All  joints  in  the  body  are  sharers  in  this  ligamentous  weakness, 
for  it  is  not  confined  to  the  articulations  of  the  limbs.  The  fibrous 
bands  which  connect  the  vertebrae  with  each  other  and  with  the 
sacrum,  the  sacrum  with  the  pelvis,  are  alike  affected ;  and  it  is  a 
conjunction  of  all  these  various  lesions,  combined  with  the  soften- 
ing of  the  bones,  and  the  weakness  of  the  muscles,  which  produces 
the  inability  to  walk,  and  the  difficulty  of  holding  the  body  upright, 
which  are  so  characteristic  of  the  disease. 

The  general  symptoms  continue  while  these  changes  are  going 
on.     The  perspiration  is  profuse,  and  the  tenderness  increases  in 


108  RICKETS. 

proportion  to  the  softening  of  the  bones.  The  appetite  may  re- 
main rav^enous,  but  more  oftener  it  diminishes,  and  the  child  shows 
a  disgust  for  food,  or  only  exhibits  a  craving  for  beer,  and  the 
more  tasty  articles  of  diet.  Sickness  frequently  occurs  at  this  time, 
for  attacks  of  gastric  derangement  often  complicate  the  disease,  and 
aggravate  it.  In  these  cases  there  is  a  sour  smell  from  the  breath, 
the  vomited  matters  are  acid,  the  bowels  either  become  constipated, 
or  there  is  diarrhoea  with  green,  slimy,  offensive  stools,  showing 
the  participation  of  the  intestinal  mucous  tract  in  the  derange- 
ment. 

The  emaciation  increases ;  the  fat  disappears,  and  the  muscles 
get  more  and  more  flabby  and  wasted.  The  loss  of  power  in  the 
muscles  is,  however,  greater  than  can  be  accounted  for  by  the 
wasting;  and  if  the  disease  be  severe,  the  child  may  be  incapable 
of  supporting  himself  in  the  slightest  degree. 

The  face  gets  old-looking ;  the  eyes  are  large  and  staring,  but 
somewhat  deficient  in  speculation  ;  and  the  general  expression  is 
placid,  although  rather  languid.  The  respiration  is  quick  and 
laborious,  and  if  there  be  much  softening  of  the  ribs,  and  conse- 
quent recession  of  the  chest  walls,  the  child's  whole  faculties 
appear  to  be  concentrated  upon  the  performance  of  the  respiratory 
act.  Such  a  child  will  give  little  trouble  to  his  attendants ;  in 
fact,  the  little  creature  has  no  breath  to  spare  for  idle  lamentations, 
and  cannot  afford  to  cry. 

The  abdomen  is  very  large,  and  often  appears  enormously  dis- 
tended when  compared  with  the  narrowed  and  distorted  chest. 
This  enlargement  of  the  belly  is  due  to  depression  of  the  dia- 
phragm and  diminished  capacity  of  the  thorax,  which  force  down 
the  liver  and  spleen  below  the  level  of  the  ribs ;  to  increased 
shallowness  of  the  pelvis;  to  the  flabby  condition  of  the  abdom- 
inal muscles  favoring  the  accumulation  of  flatus  generated  b_y  the 
digestive  derangement ;  and  in  some  cases  to  actual  increase  in 
size  of  the  liver  and  spleen. 

The  enlargement  of  the  liver  and  spleen,  when  it  occurs,  is  usu- 
ally combined  with  enlargement  and  induration  of  the  lymphatic 
glands  all  over  the  body.  The  superficial  glands  may  be  felt  in 
the  groins,  the  armpits,  and  the  sides  of  the  neck,  as  hard  round 
freely  movable  bodies,  varying  in  size  from  a  pin's  head  to  a 
sweet-pea.  The  size  of  the  spleen  may  be  greatly  increased :  the 
liver,  however,  is  seldom    much  enlarge  1,  but  its  edges  are  harder 


INTELLECT  —  COMPLICATIONS.  109 

and  sharper  than  in  health.  There  is  at  the  same  time  extreme 
emaciation  and  anaemia,  with  often  a  little  anasarca,  so  that  the 
child  has  the  peculiar  "  waxy,  greenish-yellow  tint  which  is  some- 
times seen  in  the  anoemia  of  young  women,"  ^  The  oedema  is 
sometimes  general  and  decided  ;  but  there  is  never  any  increase  in 
the  white  corpuscles  of  the  blood. 

With  regard  to  the  intellect  most  writers  have  declared  that  it  is 
precocious.  Sir  W.  Jenner,  however,  opposes  this  view.  "  Chil- 
dren, the  subjects  of  extreme  rickets,  are  almost  always  deficient 
in  intellectual  capacity  and  power.  They  are  not  idiots ;  they 
show  no  signs  of  idiocy ;  they  resemble  rather  children  of  low 
intellectual  capacity  and  power  much  younger  than  themselves." 
He  explains  the  source  of  the  error  by  the  fact,  that  rickety 
children  separated  in  consequence  of  their  physical  defects  from 
other  children,  are  necessarily  thrown  very  much  into  the  society 
of  adults,  and  therefore  catch  "their  tricks  of  expression,  their 
phrases,  and  even  some,  perhaps,  of  their  ideas."  These  children 
are  also  very  late  in  talking.  They  appear  to  be  incapable  of 
picking  up  new  words  with  the  I'eadiness  exhibited  by  healthy 
children  of  ordinary  cleverness. 

Apart  from  all  the  physical  changes  produced  by  the  disease, 
the  behavior  of  a  rickety  child  is  very  characteristic,  and  is  of 
itself  almost  sufficient  to  warrant  a  diagnosis.  The  quiet,  the 
repose  about  him,  strike  the  observer  at  once.  Such  a  child,  if  able 
to  support  himself,  will  sit  for  hours,  his  legs  stretched  out  straight 
before  him  on  the  floor,  perfectly  contented  if  only  allowed  to 
remain  unnoticed.  All  that  he  wants  is  to  be  let  alone.  A  healthy 
child  delights  in  movements ;  a  rickety  child  is  only  happy  when 
at  rest ;  his  greatest  pleasure  consists  in  inaction.  To  look  at  him 
we  are  irresistibly  reminded  of  the  other  term  of  life,  for  he 
appears  to  have  anticipated  at  least  one  consequence  of  the  weight 
of  years,  and  to  have  combined  the  patient  endurance  of  old  age 
with  the  face  and  figure  of  a  child. 

Complications. — The  state  of  extreme  debility  to  which  a  child 
suffering  from  advanced  rickets  is  reduced  naturally  favors  the 
occurrence  of  secondary  diseases  in  general ;  and  it  is  usually  to 
one  of  these  that  death  is  to  be  directly  attributed,  although,  in 
some  cases,  the  intensity  of  the  general  disease  may  be  of  itself 

'  Jenner,  Medical  Times  and  Gazette,  May  12,  1860,  p.  465. 


110  RICKETS. 

sufficient  to  carry  off  the  patient.  Measles,  whooping-cough,  and 
scarlatina  are  very  liable  to  occur,  and  to  prove  fatal ;  but  there 
are  certain  other  diseases  which  are  especially  predisposed  to  by 
rickets,  viz : — 

Catarrh  and  bronchitis. 

Diarrhoea. 

Laryngismus  stridulus. 

Convulsions. 

Chronic  hydrocephalus. 

To  catarrh  and  bronchitis  are  due  a  very  large  proportion  of  the 
deaths  in  this  disease,  and  Sir  W.  Jenner  explains  very  fully  the 
cause  of  this  great  mortality. 

At  all  ages  bronchitis  is  an  extremely  fatal  disease.  The  mucus 
which  is  thrown  into  the  tubes  impedes  the  entrance  of  air;  but 
unless  air  can  enter  freely  into  the  vesicular  structure  of  the  lung, 
mucus  cannot  be  expelled.  In  coughing  to  expel  the  mucus,  the 
lung  must  be  filled  with  air  to  the  utmost;  the  contained  air  is 
then  prevented  from  escaping  by  closure  of  the  glottis,  and  at  the 
same  time  pressure  is  brought  to  bear  upon  the  lungs  by  the  muscles 
of  expiration.  The  glottis  is  then  suddenly  opened,  and  the  air  is 
driven  out,  carrying  with  it  the  mucus  which  obstructed  the  tubes. 
The  forced  respiration  seen  in  persons  suffering  from  bronchitis  is 
merely  the  effort  made  to  draw  in  the  air  past  the  obstructing 
mucus.  A  second  impediment  to  the  entrance  of  air  into  the  lung 
is  found  also  in  the  healthy  child.  It  arises  from  the  natural 
flexibility  of  the  lower  part  of  the  thoracic  parietes,  which  yield  to 
a  certain  extent  in  inspiration  before  the  pressure  of  the  external 
air.  In  advanced  rickets,  however,  this  natural  flexibility  is  greatly 
increased  by  the  abnormal  softening  of  the  ribs,  so  that  even  when 
the  lungs  are  healthy  each  inspiration  is  only  effected  by  a  distinct 
laborious  effort.  Now  add  bronchitis  to  this  condition,  and  the 
impediment  is  extreme.  Air  cannot  enter  deeply  into  the  lungs ; 
mucus  cannot  be  expelled;  the  air,  however,  in  the  lungs  can  be, 
and  is  expelled  ;  there  is,  consequently,  collapse,  and  the  child 
dies — not  properly  speaking  from  the  collapse,  but  from  that  which 
caused  the  collapse,  viz.,  the  inability  of  the  inspired  air  to  pass 
the  obstructing  mucus. 

The  extent  to  which  the  ribs  are  softened,  and  the  amount  of 
their  recession  in  inspiration,  are  therefore  of  extreme  importance 


DIARRHCEA  —  LARYNGISMUS    AND    CONVULSIONS.       Ill 

as  regards  the  prognosis  of  broncliitis  when  it  occurs  in  rickety 
children. 

Diarrhoea. — Eicketj  chiklren  are  especially  liable  to  attacks  of 
purging.  This  may  be  accounted  for  partly  by  their  extreme  sen- 
sitiveness to  changes  of  temperature,  and  partly  by  the  unhealthy 
condition  of  the  alimentary  canal,  which  always  precedes  and 
accompanies  the  disease,  and  which  a  very  slight  additional  irrita- 
tion would  easily  aggravate  into  diarrhoea.  These  attacks  are 
exceedingly  dangerous.  We  know  that  even  healthy  children, 
seized  with  profuse  purging,  rapidly  lose  flesh,  and  soon  become 
exhausted.  A  few  hours  are  sufficient,  if  the  drain  is  severe,  to 
cause  a  marked  change  in  their  appearance  ;  their  features  quickly 
lose  the  roundness  of  youth,  and  assume  instead  the  pinched,  drawn 
characters  of  age.  Rickety  children,  already  enfeebled,  are  still 
less  able  to  withstand  the  depressing  effects  of  the  disorder,  and 
fall  victims  to  it  all  the  more  readily  in  proportion  to  the  degree 
to  which  their  strength  has  been  previously  reduced. 

Laryngismus  stridulus  and  convulsions  are  not  uncommon  com- 
plications of  rickets.  The  first,  especially,  is  almost  always  asso- 
ciated with  rickets  as  its  cause.  Whether  it  is,  as  Dr.  Gee  suggests,^ 
that  the  convulsive  tendency  and  the  rickety  state  are  both  due  to 
the  same  condition  of  general  mal-nutrition,  or  that  the  convul- 
sions are  a  secondary  result  of  the  rickety  constitution,  the  fact  re- 
mains that  in  rickets  the  special  and  the  general  convulsive  attacks 
are  frequent,  and  are  often  combined.  Out  of  fifty  cases  of  laryn- 
gismus, noted  by  Dr.  Gee,  forty-eight  were  rickety,  and  of  these 
nineteen  had  general  convulsions.  Out  of  one  hundred  and  two 
children  in  whom  general  convulsions  occurred,  forty-six  were 
rickety.  This  connection  is  exceedingly  important,  as  regards  the 
treatment  of  these  attacks.  Most  of  the  children  in  whom  this 
convulsive  tendency  is  marked  have  carpo-pedal  contractions. 

As  dentition  is  backward  in  all  these  cases,  the  laryngismus  and 
the  convulsions  are  frequently  attributed  to  teething.  The  teeth, 
however,  are  quite  innocent  of  any  share  in  the  production  of  these 
complications.  They  are  backward  as  a  consequence  of  the  arrest 
of  growth  of  bone  which  is  one  of  the  characteristics  of  the  dis- 
ease.    When  the  teeth  do  appear  they  are  often  cut  with  remark- 

'  See  an  elaborate  paper  by  Dr.  Gee  in  St.  Bartholomew's  Hospital  Reports, 
vol.  iii.  1867. 


112  EICKETS. 

able  ease,  and  whereas  the  child  had  been  formerly  subject  to  con- 
vulsions, with  or  without  apparent  cause,  the  commencement  of 
dentition  is  accompanied  by  no  such  phenomena ;  the  removal  of 
the  rickety  condition,  as  shown  by  the  evolution  of  the  teeth,  being 
coincident  with  the  disappearance  of  the  spasmodic  tendency. 

Chronic  Hydrocephalus  occasionally  complicates  the  disease,  and  is 
most  common,  according  to  Dr.  Merei,'  between  the  ages  of  eight 
and  eighteen  months.  The  fluid  may  be  in  the  lateral  ventricles,  in 
the  arachnoid  sac,  or  in  both.^  It  often  appears  to  be  a  merely 
mechanical  effusion,  the  serosity  being  thrown  out  to  fill  up  the 
space  left  when  the  cranial  cavity  becomes  enlarged  without  any 
corresponding  increase  in  the  size  of  the  brain.  In  these  cases  the 
convolutions  are  perfectly  natural,  and  show  no  signs  of  pressure. 

On  account  of  the  altered  shape  of  the  skull,  hydrocephalus  is 
often  suspected  where  it  does  not  really  exist.  The  differences  be- 
tween the  ordinary  rickety  head,  and  the  skull  expanded  by  fluid 
iu  its  cavit}^,  have  already  been  pointed  out.     (See  page  99.) 

Besides  the  complications  which  have  been  mentioned,  tubercular 
formation  may  occur  in  rickety  children.  This,  however,  is  not  a 
special  complication  of  the  disease,  and  is  comparatively  rare. 

When  death  results  from  the  intensity  of  the  general  disease, 
without  the  occurrence  of  any  of  these  complications,  the  child 
becomes  weaker  and  weaker;  he  loses  all  power  of  supporting 
himself,  and  can  hardly  move.  The  diflftculty  of  respiration,  owing 
to  the  softened  state  of  his  ribs,  absorbs  all  his  attention.  The 
face  gets  livid,  or  leaden-colored;  the  perspirations  are  extreme; 
the  tenderness  is  so  great  that  he  cannot  bear  to  be  touched ;  the 
softening  of  the  bones,  and  the  consequent  deformities,  continue, 
although  sometimes  the  bones  seem  to  get  brittle,  and  fractures 
may  occur  unless  the  child  is  moved  with  very  great  care.  The 
appetite  becomes  completely  lost;  the  body  generally  is  much 
wasted,  although  the  belly  remains  full  and  distended  ;  and  at  last 
the  child  dies  exhausted  or  asphyxiated. 

If  the  disease  terminate  favorably,  the  symptoms  gradually 
subside,  and  finally  disappear.  The  tenderness  becomes  less 
marked  ;  the  bones  cease  to  soften  ;  the  child  aj^pears  more  lively, 
and  takes  an  interest  in  what  passes  around  him.     As  the  softening 

'  Disorders  of  Infantile  Development  and  Rickets,  8vo.,  1855. 
2  Dr.  Gee,  loc.  cit. 


FAVORABLE  TERMINATION  —  PATHOLOGY.     113 

of  the  ribs  diminishes,  his  respiration  grows  less  laborious,  and  he 
will  then  begin  to  amuse  himself  with  his  toys.  The  appetite  im- 
proves, and  gets  less  capricious  ;  the  bowels  are  more  regular,  and 
the  stools  healthier-looking.  The  wasting  ceases  ;  the  child  begins 
to  gain  flesh,  while  the  belly  decreases  in  size,  and  becomes  less 
prominent.  The  head-sweats  are  less  noticed,  and  his  sleep  at  night 
is  more  tranquil,  although  for  a  long  time  he  will  continue  to  throw 
off  the  bed-clothes  at  night  unless  restrained.  Dentition  recom- 
mences, and  goes  on  rapidly  and  easily.  The  deformities  of  the 
bones  gradually  diminish  ;  the  bones  get  very  much  straighter  than 
would  be  expected  from  their  former  distortion,  become  exceed- 
ingly thick  and  strong,  and  the  enlargement  of  the  ends  of  the  long 
bones  becomes  very  remarkably  reduced.  The  muscles  also  begin 
to  be  more  developed,  and  increase  rapidly  in  size.  The  increase 
in  length  of  the  bones,  however,  is  not  rapid,  and  the  child  remains 
more  or  less  stunted,  seldom  when  full  grown  reaching  the  average 
height. 

The  rapidity  with  which  dentition  proceeds  during  recovery 
from  rickets  is  sometimes  very  striking,  and  is  well  illustrated  by 
the  following  case:  "Geo.  P.,  at  the  age  of  two  years,  had  but 
twelve  teeth,  and  could  not  stand.  The  chest  was  much  deformed, 
the  ends  of  the  long  bones  were  enlarged,  and  the  legs  were  very 
thin  and  flabby.  Treatment  was  begun  on  November  29.  On 
January  2-4  of  the  following  year  the  boy  could  walk  across  the 
room  steadying  himself  by  the  different  articles  of  furniture,  and 
by  May  16  could  walk  well  and  firmly  without  any  assistance. 
The  teeth  reappeared  as  follows :  By  April  7  he  had  cut  the  two 
upper  canines,  and  by  May  16  the  two  lower  canines;  by  May  30 
three  back  molars  had  appeared,  and  on  the  following  day,  June  1, 
the  last  remaining  tooth  pierced  the  gum.  The  treatment  con 
sisted  in  careful  regulation  of  his  diet;  in  the  administration  of 
alkalies  with  drop  doses  of  tinct.  opii,  to  improve  the  condition  of 
his  digestive  organs ;  and  afterwards  when  the  motions  wei'e  per- 
fectly healthy,  in  iron  wine  with  half-drachm  dose  of  cod-liver  oil." 

Pathology. — Rickets  is  a  general  disease,  and  affects  very  widely 
the  tissues  of  the  body.  Its  influence  is  most  manifest  in  the 
bones,  which  are  always  implicated,  but  we  find  in  addition,. 
changes  in  the  brain,  liver,  lymphatic  glands,  spleen,  muscles^  and 
often  of  every  organ  in  the  body. 

Eickets  affects  the  bones  in  three  different  ways. 
8 


114  RICKETS. 

It  interferes  with  their  growth,  not  only  temporarily,  but  per- 
manently ;  for  children  who  have  been  thus  affected  never,  as  Mr. 
Shaw  has  pointed  out,  grow  into  average  sized  adults. 

It  interferes  with  their  development,  perverting  the  process  of 
ossification,  and  rendering  the  calcareous  deposit  irregular  and 
incomplete.  Indeed,  according  to  Sir  W.  Jenner,  it  is  not  true 
ossification  at  all,  but  rather  petrifaction,  such  as  we  see  occasion- 
ally taking  place  in  enchondromata. 

But  besides  its  influence  over  the  growth  and  development  of 
bone,  rickets  produces  equally  serious  changes  in  bone  already 
completely  ossified.  It  softens  and  consumes  the  osseous  tissue,  so 
that  the  bones  lose  in  density,  in  weight,  and  in  firmness;  they 
yield  under  the  pressure  of  a  finger,  and  can  be  cut  "like  carrots 
with  a  knife.'"  This  softening  is  due  to  the  removal  of  the  lime 
salts,  which  enter  the  blood  in  a  soluble  form,  and  are  excreted  by 
the  kidneys.  Some  pathologists  have  attempted  to  explain  this 
absorption  of  lime  by  the  excessive  formation  of  the  alimentary 
canal  of  an  acid  which  has  been  variously  stated  as  lactic,  oxalic, 
phosphoric,  and  hydrochloric.  The  acid,  whatever  it  may  be,  enters 
the  blood,  and  so  assists  in  the  abduction  of  lime  from  the  bones. 
This,  however,  is  mere  hypothesis.  Since  change  probably  takes 
pkice  besides  the  loss  of  the  earthy  matter  of  the  bones,  for  in 
some  of  Lehman's  and  Marchand's  experiments  the  bones  yiekled 
no  gelatin  on  boiling. 

Anatomical  characters. — The  enlargement  of  the  ends  of  the  long 
bones  is  a  real  hypertrophy.  "In  rickets,"  says  Sir  W.  Jenner, 
"  there  is  an  exaggeration  of  the  conditions  we  find  in  the  first  stages 
of  ossification  in  the  healthy  subject ;  the  completion  of  the  process 
only  is  stayed.  There  is  great  development  of  the  spongy  tissue 
of  the  head  of  the  bone,  and  of  the  epiphysis,  and  also  of  that 
layer  of  cartilage  in  which  the  primary  deposit  of  calcareous  mat- 
ter takes  place.  The  layer  of  cartilage  in  which  the  cells  are 
arranged  in  linear  series,  instead  of  being  half  a  line,  is  from  a 
quarter  to  half  an  inch  in  breadth."-  While,  however,  great  pre- 
parations are  thus  made  for  the  process  of  ossification,  the  perform- 
ance of  that  process  is  extremely  irregular  and  inadequate.  The 
advancing  bone,  instead  of  moving  up  into  a  regular  line  into  the 

'  Trousseau,  Clinique  Medicale. 

2  Medical  Times  and  Gazette,  March  17,  1860,  p.  261. 


MORBID    CHANGES    IN    BOXES.  115 

cartilage,  consolidating  as  it  advances,  as  we  see  in  normal  ossifi- 
cation, strikes  up  at  different  points,  leaving  the  cartilage  at  other 
points  still  uncalcified,  and  these  may  remain  untouched  far  below, 
forming  specks  of  cartilage  completely  surrounded  by  bone.  In 
addition  to  this,  the  cartilage  cells  become  ossified  before  the 
matrix,  being  converted  into  lacunas  and.  imperfect  canaliculi. 
"  This  takes  place,"  says  KoUiker,  "  by  a  thickening  of  the  wall, 
and,  at  the  same  time,  a  formation  in  it  of  canalicular  cavities,"  so 
that  at  last  a  vacant  space  resembling  an  almost  perfect  lacuna  is 
all  that  is  left  of  the  cavity  of  the  cell.  The  usual  deposition  of 
granular  calcareous  particles  is  absent  from  the  matrix  at  the  bor- 
der of  ossification ;  the  changes  in  the  cartilage  cell  can  therefore 
be  more  distinctly  observed. 

According  to  Virchow,  the  abnormal  condition  of  rickety  bone 
consists  "  not  in  a  process  of  softening  of  the  old  bone,  but  in  the 
non-solidification  of  the  layers  of  new  bone  as  they  form.  The  old 
layers  of  bone  are  consumed  by  the  formation  of  medullary  spaces 
in  the  normal  manner,  and  the  new  layers  which  are  formed 
remain  soft.  Isolated  masses  of  lime  are  also  scattered  about  in 
sufficient  numbers  to  give  a  dotted  appearance  to  a  section  of  the 
cartilage,  and — to  add  to  all  the  irregularities — we  find  medullary 
spaces,  not  only  just  below  the  margin  of  calcification — where  they 
ought  to  be — but  also  far  beyond  the  border  of  calcification — 
where  they  ought  not  to  be ;  and  these  spaces  are  filled  with  a  soft 
slightly  fibrous  tissue,  with  vessels  running  up  into  them. 

Changes  also  take  place  in  the  flat  bones,  and  in  the  shafts  of 
the  long  bones.  On  section  we  see  that  the  meshes  of  the  spongy 
tissue  are  dilated,  and  that  the  cavities  are  filled  with  a  greasy, 
gelatinous  bloody  matter,  looking,  says  Trousseau,'  "like pale  red 
gooseberry  jam."  This  pulp  contains  colorless  nucleated  cells, 
with  one,  or  sometimes  two,  nuclei,  a  few  blood  corpuscles,  and  a 
large  quantity  of  free  fat.  The  periosteum  is  a  bright  rose-color 
from  injection  with  blood,  thicker  than  natural,  and  intimately 
adherent  to  the  bone  which  is  itself  more  vascular  and  less  pol- 
ished looking  than  it  ought  to  be.  The  pulp  fills  up  the  diploe  of 
the  flat  bones,  and  in  the  shaft  of  the  long  bones  is  found  filling 
the  medullary  canal  and  the  meshes  of  the  cancellated  tissue  and 

'  Clinique  Medicale. 


116  RICKETS. 

separating  the  lamellge  of  the  more  compact  part  from  one  another. 
At  the  same  time  the  tissue  itself  becomes  softer. 

As  the  disease  advances  the  outer  and  inner  tables  of  the  fiaL 
bones  become  thin,  soft,  and  elastic,  so  as  to  yield  under  the  pres- 
sure of  the  fingers.  The  bones  have  a  bluish  appearance  from  the 
color  of  the  pulp  which  fills  up  their  diploe  being  seen  through 
the  semi-transparent  bony  shell.  The  periosteum  now  increases  in 
thickness,  and,  according  to  M.  Gu^rin,^  a  red  gelatinous  matter, 
similar  to  that  which  clogs  the  diploe  and  the  meshes  of  the  can- 
cellated tissue,  is  deposited  between  it  and  the  body  of  the  bone. 
This  gelatinous  matter  gradually  thickens  and  acquires  the  consist- 
ence of  cartilage,  while  at  the  same  time  the  porosity  of  the  bone 
is  increased,  the  old  tissue  being  gradually  removed  by  interstitial 
absorption.  The  gelatinous  matter  lying  beneath  the  periosteum 
is  intimately  adherent  to  it,  coming  away  with  it  when  that  mem- 
brane is  detached.  "It  is  evidently,"  says  Trousseau,  "a  product 
of  periosteal  secretion,"  and  the  process  of  its  formation  is  analo- 
gous to  what  takes  place  in  the  production  of  callus  thrown  out  to 
unite  healthy  bone  after  fracture;  it  resembles  callus  also  in  its 
power  of  becoming  transformed  into  bony  tissue  much  more  solid 
and  dense  than  the  old  bone.  The  medullary  canal  is  narrowed 
by  the  thickening  of  its  lining  membrane,  and  by  the  deposit  of 
matter  like  that  which  fills  up  the  cancellar  spaces.  This  narrow- 
ing is  best  marked  at  the  most  pronounced  part  of  the  curve,  and 
should  the  curving  be  extreme,  the  canal  may  end  abruptly  at  this 
point,  opening  externally  under  the  periosteum.  It  would  thus 
lorm  an  obtuse  angle  with  the  other  part,  from  which  it  has  been 
separated  by  the  new  tissue  formed  in  the  hollow  of  the  curve. 
These  curvatures  in  the  shafts  of  the  bones  are  incomplete  frac- 
tures, such  as  take  place  in  bending  forcibly  a  stick  of  green  wood. 

So  long  as  the  disease  is  in  progress  the  bones  lose  more  and 
more  of  their  firmness,  getting  softer  and  softer,  so  that  they  yield 
before  the  slightest  pressure — either  the  pressure  of  the  air,  as  in 
the  distortion  of  the  ribs,  or  the  weight  of  the  body,  as  is  the  case 
with  the  limbs.  When,  however,  the  disease  becomes  arrested, 
consolidation  commences,  and  the  bones  acquire  greater  firmness 
and  consistency.  The  process  of  consolidation  is  compared  by 
Trousseau  to  the  calcification  of  callus  in  ordinai-y  fractures.     In 

'  Memoire  sur  le  Rachitis.     Paris,  1857. 


MORBID    CHANGES    IN    BONES.  117 

the  long  bones  calcareous  nuclei,  the  rudiments  of  new  bony  tis- 
sue, appear  in  the  greasy  gelatinous  matter  deposited  beneath  the 
periosteum  at  the  circumference  of  the  shaft.  These  enlarge  and 
unite ;  the  layers  of  bone  get  thicker  and  thicker ;  and  the  new 
tissue,  thus  acquiring  consistence,  hardens  gradually  into  a  com- 
pact substance  like  ivory.  In  the  flat  and  short  bones  the  effused 
matter  is  partially  absorbed,  so  as  to  restore  the  normal  spongy 
tissue.  According  to  Dr.  Yogel,'  the  occipital  bone  sometimes 
differs  from  the  other  bones  of  the  skull  in  the  changes  which  it 
undergoes.  In  the  condition  called  cranio-tabes,  which  has  already 
been  described,  spots  are  found  in  this  bone  where  the  osseous 
tissue  is  thin,  transparent,  of  a  yellowish-red  color,  and  contains 
scarcely  any  spongy  substance.  By  holding  the  bone  against  the 
light  the  extent  of  the  thinning  can  be  readily  seen.  "When  looked 
at  from  the  inside,  depressions  are  found  which  correspond  to  the 
underlying  convolutions  of  the  brain.  Dr.  Vogel  divides  the  pro- 
cess by  which  these  changes  take  place  into  two  stages :  a  first 
stage,  in  which  there  is  deficient  deposition  of  phosphates  in  the 
external  bony  layers  all  over  the  skull ;  and  a  second  stage,  in 
•which  absorption  takes  place  in  the  softened  parts  where  the  pres- 
sure of  the  brain  is  felt. 

Sometimes  the  thinning  of  the  bone  is  so  extreme  that  the  os- 
seous tissue  almost  entirely  disappears  in  the  affected  spots ;  the 
pericranium  and  the  dura  mater  then  come  into  contact,  having 
between  them  merely  relics  of  bone  still  unabsorbed. 

From  the  result  of  different  analyses  that  have  been  made  of 
rickety  bone,  it  appears  that  the  bone  contains  79  parts  of  organic 
to  21  of  inorganic  matter;  thus  differing  very  much  from  the  pro- 
portions found  in  healthy  bone,  where  the  inorganic  matters  are 
largely  in  excess  of  the  organic,  being  as  63  to  37. 

The  animal  matter  of  rickety  bone  yields  no  gelatin  on  boiling, 
and  at  an  advanced  period  of  the  disease,  is  said  by  Simon  to  yield 
neither  gelatin  nor  chondrin.  Schlonberger  and  Friedleben  have 
obtained  perfect  gluten  from  rickety  bone. 

The  softening  of  the  ribs,  and  consequent  deformity  of  the  chest, 
produce  certain  morbid  conditions  in  the  contents  of  the  thoracic 
cavity.  The  influence  exercised  by  the  softened  ribs  upon  the 
course  and  termination  of  bronchitis,  has  already  been  described ; 

'  Lehrbuch  der  Kinderkraukheitei],  von  Dr.  Alfred  Vogel.     Erlangen,  1863. 


118  EICKETS. 

but  there  are,  besides,  two  special  lesions  of  the  lung,  which  are 
invariably  present,  and  always  in  the  same  situation  in  every  case 
of  rickety  chest-distortion.  These  lesions  are  emphysema  and 
collapse. 

The  emphysema  occupies  the  whole  length  of  the  anterior  border 
of  each  lung,  extending  backwards  for  about  three-quarters  of  an 
inch  from  the  free  margin.  The  mode  of  its  production  is  ex- 
plained in  the  following  way :  At  each  inspiration  the  ribs  sink  in, 
and  the  lateral  diameter  of  the  chest  is  narrowed  at  the  part  cor- 
responding to  the  line  of  union  of  the  ribs  with  their  cartilages. 
While,  however,  the  lateral  diameter  is  thus  diminished,  the  antero- 
posterior diameter  is  increased  by  the  thrusting  forwards  of  the 
sternum.  Air,  therefore,  is  forced  in  excess  into  the  lungs  at  that 
part  so  as  to  fill  up  the  resulting  space,  and  over-distension  of  the 
air  vesicles  is  the  result. 

Collapse  of  the  lung  is  produced  by  the  recession  of  the  ribs 
during  inspiration.  The  collapsed  portion  forms  a  groove  just 
outside  the  emphysematous  part,  separating  it  from  the  healthy 
lung.  This  groove  corresponds  to  the  line  of  nodules  which  re- 
present the  enlarged  ends  of  the  ribs,  and  which  project  inwards 
into  the  interior  as  much  as,  or  even  more  than,  they  project  exte- 
riorly. During  inspiration  the  ribs  sink  in,  and  the  nodules  are 
forced  against  the  lung  beneath  them,  so  that  they  compress  the 
pulmonary  lobules  at  those  points,  and  close  them  against  the 
advancing  air. 

These  two  lesions  are,  therefore,  quite  independent  one  of  an- 
other ;  and  although  they  invariably  occur  if  there  is  much  soften- 
ing of  the  ribs,  yet  they  do  not  stand  to  one  another  in  the  relation 
of  cause  and  effect. 

The  collapse  which  is  sometimes  found  to  occupy  the  posterior 
and  inferior  parts  of  the  lung,  and  occasionally  some  parts  of  the 
upper  lobes,  is  the  result  of  plugging  of  a  tube  with  mucus.  The 
mechanism  of  this  has  already  been  described.  It  is  only  found 
in  bronchitis. 

Another  result  of  the  rickety  chest  is  the  circumscribed  opacity 
on  the  visceral  surface  of  the  pericardium,  known  by  the  name  of 
"white  patch."  This,  although  uncommon  in  children  generally, 
is  very  common  in  rickety  children.  Its  seat  is  usually  the  left 
ventricle,  a  little  above  its  apex,  just  at  the  point  where  the  heart 
at  each  beat  comes  in  contact  with  the  nodule  of  the  fifth  rib.     In 


ALBUMINOID    DEGENERATION.  119 

this  case  friction  against  the  bone  is  evidently  the  cause  of  the 
white  patch,  and  this  is  a  strong  argument  in  favor  of  the  "attri- 
tion theory"  generally.  The  same  thing  is  often  seen  on  the 
spleen,  which,  rising  and  falling  with  respiration,  is  rubbed  against 
a  projecting  rib  nodule.  It  is  distinguished  from  the  result  of 
embolism  by  not  extending  deeper  than  the  fibrous  coating  of  the 
organ. 

The  pathological  changes  which  take  place  as  a  result  of  rickets 
in  the  lymphatic  glands,  liver,  spleen,  and  other  internal  organs, 
have  also  been  described  by  Sir  W.  Jenner.  They  appear  to  be 
all  of  them  affected  with  the  same  condition,  which  he  calls 
albuminoid  degeneration,  and  which  corresponds  very  much  to 
Virchow's  amyloid  degeneration,  differing  from  it  only  in  not 
giving  the  characteristic  mahogany-brown  color  on  the  addition  of 
a  solution  of  iodine. 

All  the  organs  on  section  show  a  pale,  transparent  uniform 
surface ;  they  are  tough  and  solid  to  the  feel,  and  are  heavy  out  of 
proportion  to  their  size.  They  are  not  all  of  them  enlarged ;  the 
liver  and  lymphatic  glands  are  seldom  much  increased  in  size ;  but 
whether  enlarged  or  not,  they  exhibit  the  other  peculiarities  which 
have  been  described.  This  albuminoid  degeneration  is  not  found 
in  all  cases  of  rickets ;  it  is  limited  to  those  cases  where  the  emacia- 
tion is  marked ;  but  where  it  does  occur,  all  the  organs  seem  to 
be  alike  affected  by  it,  and  not  merely  one  or  two. 

The  spleen  varies  very  much  in  size.  Sometimes  it  can  just  be 
felt  below  the  ribs;  sometimes  it  is  very  much  enlarged.  It  may 
measure  as  much  as  eight  inches  from  above  downwards,  and  four 
inches  from  side  to  side.  "  Its  substance,"  says  Sir  W.  Jenner 
'*'  is  tough  and  elastic,  and  the  thinnest  sections  can  be  cut  with 
facility.  The  cut  surface  is  remarkably  transparent  and  smooth. 
It  is  not  unlike  what  one  might  suppose  would  be  its  appearance 
if  the  whole  organ  were  infiltrated  with  glue.  Only  a  little  pale 
blood  can  be  expressed  from  the  cut  surface.  Usually  the  organ 
is  pale  red,  but  occasionally  it  is  dark  purple.  The  more  trans- 
parent any  given  part  is,  the  paler  it  is;  the  more  transparent 
parts  are  almost  colorless.  The  splenic  corpuscles  are  sometimes 
more  readily  seen  than  in  a  healthy  spleen  ;  they  may  be  mistaken 
for  gray  tubercles.  I  have  never  seen  in  the  spleen  of  rickety 
children,  the  sago-like  little  masses  so  often  present  in  the  spleens 
of  those  who  die  of  phthisis." 


120  RICKETS. 

The  thymus  gland  is  often  enlarged,  and  exhibits  on  section  the 
usual  pale  transparent  look  from  infiltration  with  the  same  albu- 
minoid substance  as  the  other  internal  organs. 

The  brain  is  usually  larger  than  natural,  and  may  also  present 
the  signs  of  albuminoid  degeneration.  Sometimes,  however,  this 
appearance  is  not  seen,  the  increase  being  apparently  due  to  a  true 
hypertrophy.  In  a  case  noted  by  Dr.  Gee,'  this  organ  weighed 
fifty-nine  ounces;  it  was  of  natural  consistence,  not  toughened  or 
hardened,  and  the  gray  and  white  matter  appeared  to  retain  their 
normal  proportions.  In  another  case,  the  brain  weighed  forty-two 
and  a  half  ounces,  and  also  seemed  healthy,  although  of  such 
unusual  size. 

The  voluntary  muscles  are  small,  pale,  flabbj^,  and  soft,  but  do 
not  owe  this  appearance  to  fatty  degeneration.  Sir  W.  Jenner  did 
not  succeed  in  detecting  a  single  particle  of  olein  in  their  fibres. 
Under  the  microscope  their  fibres  are  "  singularly  colorless,  trans- 
parent, and  soft,"  with  the  striae  very  indistinctly  marked. 

The  urine  in  rickets  is  pale.  The  amount  of  urea  and  uric  acid 
is  diminished;  but  there  is  increase  in  the  amount  of  the  earthy 
phosphates.  This  increase  is  stated  to  be  greatest  at  the  beginning 
of  the  bone  softening,  and  to  become  less  marked  when  the  disease 
is  further  advanced,  and  the  bones  are  undergoing  distortion. 
Free  phosphoric  and  lactic  acids  have  been  observed,  and  it  is  not 
uncommon  to  find  a  sediment  of  oxalate  of  lime.  Phosphate  of 
lime  was  in  great  excess  in  a  case  recorded  by  Mr.  Solly. 

Diagnosis. — The  early  diagnosis  of  rickets  is  of  great  import- 
ance :  few  cases  are  so  readily  curable  in  their  early  stages,  or  so 
fatal  if  allowed  to  continue  unchecked.  Plumpness  is  no  proof 
of  the  absence  of  rickets,  for  a  child  may  be  extremely  fat,  and 
yet  rickety  ;  on  the  other  hand,  wasting  is  no  proof  of  its  presence, 
for  a  child  may  be  reduced  almost  to  a  skeleton  without  presenting 
a  single  symptom  of  the  disease. 

In  a  well-marked  case  of  rickets  the  head  elongated  from  before 
backwards ;  the  square,  straight,  prominent  forehead ;  the  small 
face;  the  beaded  ribs;  the  deformed  chest;  the  tumid  belly  ;  the 
twisted,  distorted  limbs;  the  immobility  and  quiet  of  the  little 
creature  as  he  sits — if  he  can  sit — with  bowed  spine  and  head 
thrown  back,  gazing  around  him  with  vacant  eyes;  all  these  cha- 

Saint  Bartholomew's  Hospital  Reports,  vol.  iii.,  1857. 


DIAGNOSIS.  121 

racteristic  symptoms  leave  no  room  for  doubt  as  to  the  nature  of 
the  disease. 

It  is  only  when  the  disorder  is  at  its  very  commencement,  or 
appears  first  about  the  end  of  the  second  year,  that  it  is  so  liable 
to  be  overlooked.  A  mild  form  of  rickets,  consisting  merely  in  a 
little  enlargement  of  the  wrists  and  ankles,  slight  beading  of  the 
ribs,  arrested  or  late  dentition,  and  a  large  fontanelle,  is  exceedingly 
common,  even  in  wealthy  families.  The  parents  from  these  signs 
alone  never  suspect  disease,  and  indeed  the  plumpness  of  the  child, 
which  is  often  very  considerable,  is  the  subject  of  much  admira- 
tion. The  absence  of  teeth  is  looked  upon  as  an  innocent  peculi- 
arity, and  cases  are  quoted  of  relations,  male  and  female,  in  whom 
the  same  tardy  dentition  was  observed.  It  is  not  until  some 
complication  arises,  or  the  disease  enters  a  new  phase,  that  any- 
thing is  noticed  to  excite  alarm.  But  late  cutting  of  the  teeth  is 
never  a  natural  condition.  If,  as  Sir  W.  Jenner  has  observed,  the 
ninth  month  passes  away  without  the  appearance  of  a  tooth,  the 
cause  should  be  carefully  inquired  for,  and  will  almost  always  be 
found  in  rickets. 

Lateness  in  walking  much  more  frequently  attracts  the  attention 
of  parents,  and  children  are  often  brought  for  advice  on  account 
of  "  weakness  in  the  legs."  In  these  cases,  owing  to  the  inability 
of  the  child  to  support  himself,  even  for  a  moment,  when  held 
upon  his  feet,  essential  paralysis  may  be  suspected.  An  examina- 
tion, however,  will  show  that  although  there  is  no  power  of  stand- 
ing, yet  power  of  movement  is  by  no  means  lost.  The  child  draws 
up  the  legs  when  the  soles  of  the  feet  are  tickled,  and  the  muscles, 
although  weak,  are  not  absolutely  powerless.  Other  symptoms  of 
rickets  are  also  present. 

When  the  want  of  muscular  power  has  increased  to  such  a 
degree  that  the  child  is  incapable  of  movement,  the  incapacity  is 
general,  and  is  not  confined  to  one  or  more  limbs.  Besides,  at 
this  stage  the  deformities  of  bone  are  usually  well  marked,  and 
the  chest  distortion  is  very  great. 

Eelaxation  of  the  ligaments,  and  consequent  unnatural  mobility 
of  the  joints,  are  almost  always  due  to  rickets.  They  are  common 
results  of  the  disease  when  it  occurs  after  the  end  of  the  second 
year,  and  may  be  present  although  there  is  no  osseous  deformity, 
and  very  little  enlargement  of  the  ends  of  the  bones.  All  the 
articulations  are  affected,  but  the  knees  and  ankles  seem  to  suffer 


122  RICKETS. 

most,  as  tbey  bear  the  weight  of  the  body.  The  yielding  of  the 
ligaments  of  these  joints  may  be  so  great  as  to  make  walking  diffi- 
cult or  even  impossible,  but  where  the  relaxation  is  extreme  there 
is  usually  combined  with  it  more  or  less  softening  and  distortion 
of  the  bones. 

In  rickety  children,  before  cutting  for  stone,  the  size  of  the 
pelvis  should  be  carefully  studied,  for  narrowness  of  the  outlet 
may  create  great  difficulty  in  removing  the  calculus.  By  noting 
the  degree  of  stunting  and  distortion  of  the  lower  limbs,  a  fair 
guess  may  be  made  as  to  the  degree  to  which  the  pelvis  is  likely 
to  have  suft'ered  from  arrest  of  development  and  softening  of  its 
bones.  An  examination  jjer  anum  will,  however,  at  once  remove 
any  doubts :  by  the  finger  introduced  into  the  rectum  we  can 
readily  explore  the  entire  pelvic  cavity,  and  the  size  and  capacity 
both  of  the  brim  and  of  the  outlet  can  by  this  means  be  satisfac- 
torily ascertained. 

Mollities  ossium,  which  has  been  called  the  rickets  of  adults, 
appears  to  be  a  completely  different  disease :  it  goes  on  always 
from  bad  to  worse  ;  re-ossification  never  takes  place ;  and  it  induces 
fatty  degeneration  of  the  bones — a  condition  never  found  in  rickets. 

Prognosis. — The  danger  of  rickets  lies  principally  in  the  com- 
plications. As  long  as  the  disease  remains  simple,  and  the  bone- 
softening  is  not  extreme,  the  prognosis  is  very  favorable. 

In  estimating  the  danger  of  any  particular  case,  attention  should 
always  be  paid  to  two  points : — 

The  amount  of  chest  distortion. 

The  presence  or  absence  of  albuminoid  degeneration  of  the 
spleen  and  glandular  system  generally. 

If  the  chest  is  much  distorted,  and  the  softening  of  the  ribs  is 
great,  there  is  always  cause  for  anxiety.  Owing  to  the  difficulty 
of  respiration  iu  these  cases,  there  is  deficient  aeration  of  the  blood 
(shown  by  the  lividity  of  the  lower  eyelid  and  of  the  mouth),  and 
consequent  deficient  oxidation  and  removal  of  waste  matter.  The 
slightest  catarrh,  as  has  been  before  explained  (see  p.  110),  adds  a 
further  obstacle  to  due  aeration;  and  catarrhs  are  always  liable  to 
occur,  however  carefully  chills  may  be  guarded  against,  owing  to 
the  extreme  sensitiveness  of  a  rickety  child  to  changes  of  tempera- 
ture. Under  such  circumstances  the  child's  life  is  always  in  danger, 
for  a  slight  cold,  which  in  a  healthy  child  would  be  scarcely  worth 
notice,  or  which  would  be  easily  treated  by  domestic  remedies, 


PROGNOSIS  —  CAUSES.  123 

will  be  sufficient  in  a  rickety  child  to  cause  fatal  collapse  of  the 
lungs.  If  a  child,  the  subject  of  this  disease,  begins  to  cough,  no 
prognosis  should  be  hazarded  until  the  movements  of  the  chest 
during  respiration  have  been  carefully  watched;  and  here  more 
useful  information  can  often  be  gained  by  the  eye  than  by  the 
stethoscope.  The  danger  is  in  direct  proportion  to  the  degree  of 
recession  of  the  ribs  during  inspiration. 

The  danger  of  albuminoid  degeneration  of  the  glandular  system 
is  shown  by  the  emaciation  with  which  it  is  always  accompanied. 
The  weakness  of  the  child  in  these  cases  reaches  its  height,  and 
the  impediment  to  the  proper  elaboration  of  nutritive  material  set 
up  by  such  a  condition  of  the  glands  forms  a  great  obstacle  to 
efficient  treatment.     These  cases  are  usually  fatal. 

On  account  of  the  danger  of  catarrh,  those  disorders  in  which 
it  is  a  prominent  symptom  are  of  course  especially  formidable  to 
rickety  children.  On  this  account  measles  and  whooping-cougb 
are  greatly  to  be  dreaded. 

Of  the  other  complications,  diarrhoea  is  the  most  serious.  Con- 
vulsions are  not  necessarily  fatal,  although  they  increase  the  gravity 
of  the  case.  Sometimes,  though  rarely,  laryngismus  stridulus  causes 
death. 

The  combination  of  hydrocephalus  with  rickets  is  seldom 
attended  with  danger. 

No  indication  for  prognosis  can  be  derived  from  the  age  of  the 
child.  A  slight  degree  of  rickets  is  very  common  in  infants  of 
seven  months  old,  and,  when  the  causes  which  produced  it  are 
removed,  it  ceases  as  readily  in  them  as  in  older  children.  The 
severity  of  the  disease  depends  upon  the  intensity  and  the  continu- 
ance of  the  causes  of  which  it  is  the  result. 

Causes. — Rickets  is  usually  ranked  amongst  the  diathetic  dis- 
eases of  childhood,  but  its  claims  to  such  a  position  are  by  no 
means  indisputable.  A  diathesis  is  defined  by  Dr.  Aitken,^  as 
"that  character  of  the  constitution  which  tends  to  the  repeated 
expression  of  some  form  of  ill-health,  always  in  the  same  way." 
In  other  words,  it  is  a  constitutional  predisposition  to  repeated 
manifestations  of  a  certain  invariable  form  of  disease.  Now,  in 
rickets  there  is,  strictly  speaking,  no  constitutional  predisposition. 

'  Science  and  Practice  of  Medicine,  by  "W.  Aitken,  M.D.,  Edinburgh,  2d 
edition,  1863,  vol.  i.  p.  212. 


124  RICKETS. 

It  is  tbe  result  of  certain  known  causes,  without  whicli  the  disease 
cannot  be  produced,  but  under  the  influence  of  which  any  child 
whatever  (with  certain  exceptions,  to  be  afterwards  noticed)  will 
become  rickety.  That  the  disease  occurs  amongst  the  children  of 
the  rich  as  well  as  amongst  the  poor  is  no  argument  against  this 
view,  for  wealth  cannot  buy  judgment,  and  education  is  no  guar- 
antee against  foolish  indulgence.  We  know  that  a  child  may  be 
in  reality  starving,  although  fed  every  day  upon  the  richest  food, 
for  he  is  nourished,  not  in  proportion  to  the  nutritive  properties  of 
the  food  he  swallows,  but  in  proportion  to  his  capability  of  digest- 
ing what  is  given  to  him.  If,  therefore,  he  is  supplied  with  food 
unsuited  to  his  age,  the  result  is  the  same,  whether  he  live  in  a 
palace  or  a  cottage. 

Cases  occasionally  occur  where  the  mother,  exhausted  by  chronic 
disease,  or  other  depressing  cause,  bears  children  feeble  at  their 
birth,  and  who  very  rapidly  become  rickety.  But  these  are  not 
true  cases  of  constitutional  predisposition.  The  child  is  born 
suffering  already  from  the  effects  of  deficient  nutrition  in  the  womb. 
He  is  then  at  once  suckled  with  poor  watery  milk,  or  is  brought 
up  by  hand  and  stuffed  with  all  the  hurtful  trash  with  which  the 
ignorance  of  mothers  prompts  them  to  supply  the  deficiencies  of 
their  milk.  The  natural  result  of  such  imperfect  nourishment 
follows,  and  rickets  declares  itself.  But  here  the  child  can  only 
be  said  to  have  been  predisposed  to  rickets  in  the  sense  that  he 
was  born  suffering  from  a  condition  which  rickets  is  the  final  and 
most  striking  stage.  Eickets  does  not  produce  malnutrition,  but 
malnutrition  produces  rickets.  The  infant  is  not  born  weakly 
because  he  has  a  rickety  predisposition,  but  he  falls  a  victim  to 
rickets  because  he  was  born  weakly. 

It  occasionally  happens  that  a  child  is  born  suffering  from  the 
catarrh  of  whooping-cough,  but  he  cannot  be  said  to  have  a  con- 
stitutional predisposition  to  pertussis  because  after  the  lapse  of  a 
certain  time  he  begins  to  whoop.  The  disease  was  present  at 
birth,  although  it  had  not  at  that  time  reached  the  spasmodic  stage. 
So  also  in  the  case  of  early  rickets,  the  disease  really  began  in  the 
womb,  and  only  underwent  further  development  after  the  entrance 
of  the  child  into  the  world. 

Besides,  for  the  full  development  of  the  disease,  it  is  essential 
that  the  same  causes  by  which  nutrition  was  first  rendered  defec- 
tive should  continue  in  operation.     If  measures  are  taken  to  im- 


CAUSES.  125 

prove  nutrition,  this  result  does  not  follow,  for  when  well  cared 
for,  and  supplied  with  proper  nourishment,  the  child  in  all  cases 
becomes  strong  and  healthy.  Rickets  is  no  disease  which  must 
run  its  course.  By  judicious  treatment  it  may  be  stayed  at  any 
point  of  its  career ;  and  the  treatment  required  is  merely  food — • 
food  which  nourishes,  and  drugs  which  are  not  so  much  medicines 
as  food  under  another  name. 

Again,  in  the  true  diathetic  diseases  of  children,  as  tubercle  and 
syphilis,  hereditary  tendency  plays  a  very  important  part,  but  in 
the  case  of  rickets  there  is  very  little  evidence  of  such  a  cause. 
Out  of  the  thousands  of  rickety  children  there  will  no  doubt  be 
many,  one  or  the  other  of  whose  parents  was  rickety  before  them ; 
but  the  same  thing  may  be  said  of  any  other  common  disorder. 
It  is  always  difficult  where  many  conditions  unite  in  the  causation 
of  a  disease  to  separate  the  share  which  hereditary  tendency  takes 
in  its  production,  but  no  special  facts  have  yet  been  brought  for- 
ward to  show  that  rickety  parents  are  more  likely  to  have  rickety 
children  than  parents  who  have  been  altogether  free  from  the  dis- 
ease— the  other  conditions  remaining  the  same. 

Rickets,  then,  is  not  a  diathetic  disease  in  the  sense  in  which  tu- 
berculosis and  syphilis  are  diathetic  diseases.  Before  the  altera- 
tions in  structure  actually  occur  there  is  nothing  in  the  appearance 
of  the  child  to  indicate  the  disease  from  which  he  is  about  to  suffer. 
It  is  acquired  under  the  influence  of  certain  causes,  lasts  as  long 
as  those  causes  continue  in  operation,  and,  unless  the  structural 
charges  are  so  extensive,  and  the  general  strength  so  reduced,  as 
to  forbid  recovery,  passes  off  when  the  causes  are  removed. 

These  causes  must  be  looked  for  in  all  those  conditions  which 
interfere  with  the  proper  nutrition  of  the  child.  Ill  health  or  weak 
constitution  of  the  mother  affecting  the  nutrition  of  the  foetus  in 
utero,  and  after  birth  of  the  child  deteriorating  the  quality  of  the 
breast-milk;  improper  feeding  generally,  ill- ventilated  rooms, 
damp,  cold,  dirt,  want  of  sunlight,  want  of  exercise.  The  con- 
tinued influence  of  these  causes  will  produce  the  disease,  or  rather, 
will  produce  that  unhealthy  condition  of  the  body  of  which 
rickets  is  the  direct  consequence.  The  preliminary  stage,  that 
which  marks  the  commencement  and  progress  of  malnutrition, 
and  in  which  the  strength  is  being  gradually  reduced  to  the  point 
at  which  rickets  begins,  may  be  long  or  short  according  to  the  de- 
gree of  vigor  of  the  child,  and  the  degree  of  intensity  with  which 


126  RICKETS. 

the  causes  operate,  or  may  even  be  absent  altogether.  Its  place 
may  be  taken  by  any  disease  which  interferes  seriously  with  the 
assimilative  power,  and  causes  sufficient  impairment  of  the  general 
strength.  We  thus  get  another  set  of  causes,  which  may  either 
act  independently  of  the  others,  or  may  most  powerfully  intensify 
their  influence.  Thus  rapidly  recurring  attacks  of  diarrhoea, 
chronic  vomiting,  measles,  bronchitis,  broncho-pneumonia,  in  fact, 
all  the  exhausting  diseases,  may  have  this  effect. 

Too  early  weaning  is  sometimes  stated  to  be  a  special  cause  of 
the  disease.  It  is  no  doubt  true  that  to  deprive  a  young  child  of 
breast  milk  which  he  can  digest,  and  to  supply  him  instead  with 
food  which  he  cannot  digest,  is  certain  to  be  hurtful.  In  England, 
however,  the  tendency  is  rather  to  keep  the  child  too  long  at  the 
breast,  to  accustom  him  to  look  to  that  for  his  sole  nourishment 
after  the  time  when  some  additional  food  is  required.  In  either 
case  the  supply  of  nutritive  material  is  equally  deficient,  and  the 
effect  upon  the  health  of  the  child  must  be  equally  unfavorable. 

The  connection  between  syphilis  and  rickets  is  interesting;  by 
some  writers  great  importance  is  attributed  to  the  influence  of  the 
former  disease  as  a  cause  of  rickets,  while  others  have  denied  such 
influence  altogether.  That  syphilitic  infants  do  occasionally  be- 
come rickety,  no  one  who  has  been  a  close  observer  of  children's 
diseases  can  venture  to  doubt.  A  child  may  become  the  subject  of 
rickets  after  the  disappearance  of  the  syphilitic  symptoms,  or  even 
while  the  body  is  yet  covered  by  the  specific  rash.  Such  cases 
are,  however,  the  exception,  and  are  usually  mild.  The  author  has 
never  as  yet  met  with  an  example  of  severe  rickets  occurring  in  a 
syphilitic  child. 

With  regard  to  the  influence  of  tubercle,  rickety  children  may 
become  tubercular,  and  a  phthisical  mother  may  bear  rickety 
children;  but  a  child  in  whom  the  tubercular  diathesis  is  marked 
seldom,  if  ever,  becomes  rickety.  It  is  also  rare  to  find  a  case  of 
rickets  occurring  in  a  family  the  other  children  of  which  are  the 
subjects  of  tuberculosis. 

Prevention. — If  any  of  the  former  children  of  the  family  have 
been  rickety,  especial  attention  must  be  paid  to  the  diet  and  gene- 
ral management  of  the  new-born  babe.  The  mother  may  still 
suckle  the  infant  during  the  first  month,  but  after  that  time 
she  should  give  up  all  idea  of  rearing  the  child  from  her  own 
breast,  and  a  wet  nurse  should  be  provided.     If  from  circum- 


PREVENTION — TREATMENT.  127 

stances  this  is  impossible,  the  breast-milk  must  be  limited  to  two 
meals  a  day ;  the  child  being  fed  at  other  times  upon  ass's  milk,  or 
cow's  milk  and  lime-water,  as  recommended  in  an  earlier  part  of 
this  volume.  At  the  same  time,  all  the  other  precautions  so 
essential  to  perfect  health  must  be  carefully  observed.  Perfect 
cleanliness,  warm  clothing,  fresh  air,  well-ventilated  rooms,  sun- 
light, are  all  indispensable.  If  the  parents  reside  in  a  cold,  damp 
situation,  the  child  should,  if  possible,  be  removed  to  a  neighbor- 
hood where  the  quality  of  the  air  is  drier  and  more  bracing.  For 
full  particulars  as  to  the  best  method  of  preventing  the  occurrence 
of  rickets  the  reader  is  referred  to  the  section  on  the  treatment  of 
simple  atrophy.  If  the  management  of  the  child  be  conducted  ac- 
cording to  the  rules  there  laid  down,  rickets  cannot  occur,  for  the 
causes  which  produce  the  disease  will  not  be  in  operation. 

Treatment. — In  the  treatment  of  rickets,  our  first  care  must  be  to 
endeavor  to  restore  healthy  nutrition.  This  can  only  be  done  by 
attention  to  diet  and  to  general  hygiene,  taking  care  at  the  same 
time  to  correct  any  disordered  condition  of  the  alimentary  canal 
which  may  be  present  to  interfere  with  the  proper  digestion  and 
assimilation  of  the  food  supplied.  This  is  indispensable  as  a  first 
step,  for  to  give  tonics  while  the  causes  which  have  produced  the 
disease,  and  sustain  it,  continue  in  operation,  is  a  course  which  can- 
not possibly  be  attended  with  any  good  result. 

In  almost  all  cases  the  bowels  will  be  found  to  be  rather  relaxed, 
two  or  three  stools  being  passed  in  the  course  of  the  day,  consist- 
ing of  offensive,  putty-like  matter,  mixed  largely  with  mucus, 
often  greenish,  and  occasionally  streaked  with  blood,  from  the 
straining  efforts  with  which  they  are  evacuated.  The  fetor  is  due 
to  decomposition  of  the  undigested  food.  It  is  best  to  commence 
the  treatment  with  a  gentle  laxative,  such  as  a  teaspoon ful  of 
castor  oil,  or  a  small  dose  of  rhubarb  and  soda,  and  the  bowels 
having  been  thus  relieved,  alkalies  should  be  given,  with  a  little 
opium,  in  some  aromatic  water.  The  following  prescription  is 
useful  in  these  cases,  or  some  of  the  medicines  ordered  for  a  simi- 
lar condition  of  the  bowels  in  the  treatment  of  simple  atrophy  may 
be  adopted : — 

^..     Tinct.  opii,  n\^xij  ; 
Sodse  bicarb.,  gjss ; 
Sp.  ammon.  aromat.,  5j  > 
Syrupi  ziiigib.,  §ss  ; 
Aq.  cinuamomi,  ad  3iij.     M.     5'j  ter  die. 


128  RICKETS. 

The  opium  is  of  great  use  in  diminishing  the  abnormal  briskness 
of  the  peristaltic  action  of  the  bowels,  and  should  never  be  omitted 
from  the  mixture  so  long  as  the  stools  present  the  appearances 
which  have  been  described.  Under  such  or  similar  treatment  the 
motions  will  be  found  in  a  few  days  to  assume  a  more  healthy 
character,  griping,  if  previously  present,  will  be  diminished,  or 
will  have  altogether  ceased,  and  the  general  condition  of  the  patient 
will  be  much  improved.  At  the  same  time  the  diet  of  the  child 
must  be  regulated  to  suit  the  degree  of  debility  to  which  he  may 
be  reduced,  remembering  that  the  greater  his  weakness,  the  more 
nearly  does  his  digestive  power  resemble  in  degree  that  of  a  new- 
born infant.  Full  directions  about  diet  have  already  been  given 
in  former  chapter  (see  Treatment  of  Simple  Atrophy),  and  need 
not  here  be  repeated.  It  may,  however,  be  remarked,  that  it  will 
usually  be  found  necessary  very  greatly  to  reduce  the  quantity  of 
farinaceous  matter  which  is  being  taken.  Under  the  mistaken 
notion  that  such  food  is  especially  nutritious  and  easy  of  digestion, 
weakly  children,  whatever  their  age  may  be,  are  commonly  made 
to  depend  for  their  support  chiefly  upon  sago,  arrowroot,  tapioca, 
and  similar  articles  of  diet.  The  amount  of  this  food  must  be 
therefore  considerably  restricted,  according  to  the  rules  already 
laid  down,  and  its  place  should  be  supplied  by  milk,  gravy,  strong 
beef-tea,  minced  meat  once  cooked,  yelks  of  eggs  lightly  boiled,  «Scc., 
according  to  the  age  and  strength  of  the  child. ^ 

Plenty  of  fresh  air  is  indispensable  to  successful  treatment  of 
rickets.  The  child  should  be  taken  out  regularly  into  the  open 
air,  and  as  he  gets  gradually  stronger  should  pass  more  and  more 
of  his  time  out  of  doors.  The  qualit}'-  of  the  air  is  of  much  im- 
portance, and  sea-side  places  where  the  air  is  dry  and  bracing,  as 
Lowestoft,  Scarborough,  Brighton,  and  Eastbourne,  are  especially 
to  be  recommended. 

Great  attention  must  be  paid  to  the  clothing.  The  belly  should 
be  kept  covered  with  a  flannel  bandage,-  and  the  child  should  be 
dressed  from  head  to  foot  in  flannel  or  merino. 

Great  cleanliness  must  be  observed.  The  whole  body  should  be 
well  washed  every  morning  with  soap  and  warm  water,  and  be 
sponged  every  evening  with  warm  water ;  and  as  he  gets  stronger, 

1  See  Chap.  XL,  Diets  5,  6,  7,  8,  10,  11,  and  18. 

*  The  abdominal  bandage  has  another  use  in  retarding  the  too  rapid  descent  of 
the  diaphragm.     This,  when  the  bones  are  much  softened,  affords  great  relief. 


INTERNAL    REMEDIES.  129 

warm  or  tepid  sponging  with  salt  water  may  be  used  to  the  back 
and  loins.  The  bed  and  bedding  should  be  removed  from  the 
room  every  morning,  and  be  freely  exposed  to  the  air ;  the  sheets 
must  be  changed  frequently  and  must  be  carefully  aired.  The 
ventilation  of  the  nurseries  must  be  attended  to,  and  at  night  a 
lamp  placed  in  the  chimney  is  useful  to  promote  a  free  current 
of  air. 

The  influence  of  the  preceding  measures  is  usually  most  marked, 
and  it  is  at  this  time  that  tonic  medicines  are  so  valuable.  They 
ought  not,  however,  to  be  given  until,  by  suitable  treatment,  the 
motions  have  become  healthy  and  the  tongue  clean. 

Iron  is  one  of  the  most  important  medicines  we  have  at  our  dis- 
posal.    A  good  form  for  its  administration  is  the  following : — 

I^.  Liq.  ferri  pernltratis, 

Acidi  nitrici  diluti,  aa  3ss  ; 

Syrupi  zingiberis,  §j  ; 

lufusum  calumbae,  ad  ^iij.     M.     5U  t^f  <ii®» 

If  the  debility  is  very  great,  the  ammonio-citrate  may  be  given 
with  sal  volatile — 

R.  Ferri  et  ammonise  citratis,  gr.  xij  ; 
Spirit,  ammonio  aromat., 
Sp.  chloroformi,  aa  ^ss  ; 
Infusum  calumbse,  ad  |iij.     M.     5'j  ter  die. 

or  the  tincture  of  the  sesquichloride  may  be  combined  with  dilute 
hydrochloric  acid  and  spirits  of  chloroform  in  the  same  infusion. 
Other  preparations  of  iron  are  recommended,  as  the  syrup  of  the 
iodide,  the  syrup  of  the  phosphate,  and  reduced  iron.  The  latter, 
from  its  small  bulk,  is  very  convenient,  and  may  be  given  in  doses 
of  half  a  grain  three  times  a  day. 

Chalybeate  waters,  such  as  those  of  Tunbridge  Wells,  are  also 
of  service. 

Quinine  is  very  useful.  Sir  William  Jenner  recommends  half 
a  grain  of  the  alkaloid  to  be  given  with  one  or  two  drops  of  dilute 
sulphuric  acid,  in  a  teaspoonful  or  two  of  steel  wine.  The  double 
citrate  of  quinine  and  iron  is  a  good  form ;  three  or  four  grains 
may  be  dissolved  in  glycerine,  and  given  three  times  a  dav. 

God-liver  oil  is  an  important  remedy.     It  should  not,   however, 

be  given  in  too  large  doses.     Ten  to  twenty  drops  may  at  first  be 

poured  into  each  dose  of  the  mixture,  and  the  quantity  can  be 

gradually  increased  to  a  teaspoonful.     During  its  administration 

9 


130  EICKETS. 

the  stools  should  be  examined  from  time  to  time.  Any  smell  in 
them  of  the  oil  is  a  sign  that  more  is  being  given  than  can  be 
digested,  and  the  quantity  must  therefore  be  reduced. 

Tannin  is  recommended  by  Dr.  Alison.  It  may  be  given  in 
doses  of  from  half  a  grain  to  a  grain,  two  or  three  times  a  day,  in 
a  little  dilute  nitric  acid.  The  author  has  seen  very  marked 
improvement  follow  the  use  of  this  drug. 

Nux  vomica  has  been  advocated  by  some  authors,  but  on  account 
of  the  tendency  to  convulsions  so  often  present  in  this  disease,  it 
must  be  given  with  very  great  caution.  It  is  well  to  postpone  its 
use  until  some  improvement  has  already  taken  place,  and  the  evo- 
lution of  the  teeth  has  recommenced.  It  will  then  be  a  useful 
addition  to  the  other  medicines. 

There  is  little  to  be  done  in  the  way  of  special  treatment  of  the 
bone  deformities.  The  child  should  be  prevented  as  much  as 
possible  from  walking  until  reconsolidation  of  the  bones  has  suffi- 
ciently advanced.  Careful  watching,  however,  is  required  to  pre- 
vent his  getting  upon  his  feet,  for  as  his  strength  improves  his 
delight  in  his  newly-acquired  power  is  prodigious,  and  he  seems 
anxious  by  incessant  activity  to  make  up  for  his  previously  enforced 
quiet.  Sir  W.  Jenner  has  recommended  that  splints  which  project 
below  the  feet  should  be  applied  to  the  legs.  These,  if  properly 
arranged,  effectually  prevent  his  walking,  and,  if  light  and  care- 
fully padded  may,  to  a  certain  extent,  reduce  the  deformity.  They 
should,  however,  only  be  applied  while  the  bones  are  still  soft,  and 
must  on  no  account  be  used  during  the  progress  of  consolidation. 

When  the  tenderness  has  subsided,  the  spine,  and  back  gene- 
rally, are  much  strengthened  by  careful  shampooing.  Each  morn- 
ing, after  his  bath,  the  child  should  be  laid  upon  his  face  on  the 
bed,  and  the  whole  back  should  be  well  and  firmly  rubbed  with 
the  open  hand  from  the  neck  to  the  buttocks.  The  frictions  should 
be  continued  for  about  ten  minutes.  In  the  evening  the  same 
process  may  be  repeated  before  the  child  is  put  to  bed. 

In  cases  where  the  ligaments  of  the  joints  are  very  weak  and 
relaxed,  a  carefully  applied  elastic  bandage  affords  the  best  sup- 
port. 

Treatment  of  the  complications. — The  first  symptoms  of  catarrh 
should  always  be  attended  to  at  once,  for  there  is  no  complication 
which  is  so  dangerous  to  rickety  children. 

The  whole  chest  should  be  immediately  covered  with  a  hot 


TREATMENT    OF    CATARRH.  131 

linseed-meal  poultice  frequently  renewed,  and  the  following  mixture 
should  be  ordered : — 

]^.  Potas.  iodidi,  gr.  v ; 
Potas.  nitratis,  gj  ; 
Liq.  amnion,  acetatis,  ^iij  ; 
Syrupi  simplicis,  §j  ; 
Aq.  cinnamomi,  ad  giij.     M.     5ij  quarU  quaque  horsl. 

The  object  is  to  produce  as  rapidly  as  possible  free  secretion 
from  the  bronchial  tubes,  for  the  tough  mucus  which  is  first  se- 
creted lines  the  walls  of  the  air-tubes,  greatly  diminishing  their 
calibre,  and  also  is  apt  to  form  plugs  which,  driven  farther  and 
farther  into  the  tubes,  act  as  valves,  permitting  egress,  but  forbid- 
ding ingress  of  the  air.  This  is,  as  has  already  been  explained, 
the  cause  of  the  collapse  so  often  found  after  death  occupying  the 
posterior  and  inferior  parts  of  the  lung.  The  thinner  the  secretion, 
the  smaller  the  liability  to  the  formation  of  these  plugs,  and  there- 
fore the  less  the  danger  of  collapse. 

When  the  cough  has  become  quite  loose,  a  little  ipecacuanha 
wine,  with  a  few  drops  of  sal  volatile,  may  be  added  to  the  mix- 
ture, and  oxymel  of  squill  may  be  substituted  for  the  simple 
syrup. 

If  the  debility  is  very  great,  a  little  wine  or  a  few  drops  of  pale 
brandy  can  be  given  every  few  hours  while  the  mixture  is  being 
taken,  but  no  stimulating  expectorants  should  be  prescribed  until 
the  secretion  is  copious. 

If  there  is  much  rattling  of  mucus  in  the  chest  during  respiration, 
a  teaspoonful  of  vinum  ipecacuanhse  may  be  given  at  once,  and  be 
repeated  every  ten  minutes  until  vomiting  is  produced.  An  emetic, 
by  its  mechanical  action,  helps  to  clean  the  tubes  of  mucus. 

When  diarrhoea  occurs,  it  must  be  checked  as  rapidly  as  possi- 
ble, for  the  exhaustion  it  induces  in  a  child  already  enfeebled  is 
extreme.  The  following  rules  will  be  found  useful  in  these  cases, 
and  in  the  acute  diarrhoeas  of  children  generally. 

If  the  tongue  is  furred  white  or  yellow,  the  skin  hot,  the  belly 
hard,  and  the  motions  green  and  slimy,  with  much  straining  and 
griping  pain,  give  an  aperient  of  rhubarb  and  soda,  or  castor  oil, 
followed  by  a  mixture  containing  magnesia  with  an  aromatic : — 

I^.  Magnesise,  3j  ; 
Syrupi  zingib., 
Mucilag.  acacise,  aa  §ss  ; 
Aquam  carui,  ad  §iij.     M.     5j  t®"^  <ii6. 


132  RICKETS. 

If  the  tongue  is  furred  white  or  yellow,  skin  hot,  the  belly  soft, 
the  motions  Tpale,  frothy,  and  sour-smelling,  without  straining,  give 
a  mixture  containing  chalk,  catechu,  and  aromatic  confection. 

If  the  tongue  is  clean  and  smooth,  and  the  motions  dark,  watery, 
and  stinking,  with  straining,  give  opium.  If  the  diarrhoea  con- 
tinues, acetate  of  lead  may  be  added : — 

^.  Plumbi  acetatis,  gr.  viij  ; 
Acidi  acetici  dil.,  Ti\xx  ; 
Tinct.  opii,  TTLvj  ; 
Syrupi  simplicis,  §ss  ; 
Aquam,  5Jss.     M.     5J  ter  die. 

If,  in  spite  of  this,  the  diarrhoea  still  goes  on,  the  treatment 
recommended  under  the  head  of  chronic  diarrhoea  must  be  re- 
sorted to. 

When  either  of  these  complications  (diarrhoea  or  catarrh)  are 
present,  the  diet  must  be  at  once  altered  to  suit  the  temporarily 
reduced  power  of  digestion. 

The  treatment  of  convulsions  and  laryngismus  stridulus  is  in- 
cluded in  the  treatment  of  the  general  disease  of  which  they  form 
such  common  complications.  By  removing  the  rickety  condition 
the  tendency  to  convulsions  also  disappears.  During  the  actual 
presence  of  these  attacks.  Dr.  Gee^  recommends  the  bromide  of 
potassium  or  ammonium  to  be  given  in  four-grain  doses  three  or 
four  times  a  day  to  a  child  of  one  year  old,  and  to  be  continued  for 
a  week  or  two  after  the  fits  have  subsided. 

Laryngismus  stridulus  may  often  be  cured  at  once  by  bathing 
the  child's  whole  body  three  times  a  day  with  water  of  the  temper- 
ature of  60°  Fah. 

The  presence  of  a  large  head  in  combination  with  convulsive  at- 
tacks often  gives  rise  to  a  suspicion  that  the  fits  are  due  to  hydro- 
cephalus, and  very  active  treatment  is  resorted  to,  often  with  the 
most  disastrous  results.  Eickety  children  will  not  bear  lowering 
measures  at  any  time,  and  to  reduce  the  strength  while  convulsions 
are  actually  present  is  only  to  increase  the  number  and  the  intensity 
of  the  fits. 

•  Saint  Bartholomew's  Hospital  Reports,  vol.  iii.,  1867,  p.  103. 


CHAPTEE     V. 

INHERITED    SYPHILIS. 

Inherited  Syphilis. — Appearance  of  first  symptoms — Before  birth — At  birth — 
After  birth — Sleeplessness  at  night — Snuffling — Necrosis  of  nasal  bones — 
Eruptions  on  skin — Seat — Varieties — Scaly  patches — Ecthymatous  pustules — 
Papules — Tubercular  spots — Ulcers — Mucous  patches — Cracks  and  fissures — 
Complexion — Cry — Openness  of  fontanelle — Influence  of  the  disease  on  gene- 
ral nutrition — Affections  of  internal  organs — Hair — Local  peritonitis — Spleen 
— Delayed  Symptoms — Syphilitic  teeth. 
Diagnosis. — By  general  symptoms — By  history — By  examination  of  other  child- 
ren of  the  same  family. 
Causes. — Transmission  of  taint  from  father — From  mother — Mother  seldom  es- 
capes if  father  aflfected — CoUes'  law — Twins  not  always  equally  afi'ected — 
Other  modes  of  infection. 
Prognosis. — From  Jobservation  of  parents — Of  child — Importance  of  considering 
the  intensity  of  the  general  cachexia — Importance  of  certain  special  symp- 
toms. 
Prevention.  Treatment. — Two  objects — Treatment  to  be  begun  early — Remarks 
on  the  non-mercurial  treatment — Treatment  by  mercury — DiflFerent  prepara- 
tions— External  applications — Ointment — Mercurial  baths — Improve  general 
nutrition — Diet — Peculiarities  of  the  milk  in  syphilitic  mothers — Other  foods 
— Cod-liver  oil — Warmth — Cleanliness — Treatment  of  vomiting  and  diar- 
rhoea— Local  applications — Tonics. 

m 
Inherited  Syphilis  may  manifest  its  presence  in  the  cbild  at 
three  different  periods — viz.,  before  birth,  at  birth,  or  after  birth. 

If  before  birth,  it  occurs  usually  from  the  fifth  to  the  seventh 
month  of  intra-uterine  life.  The  child  dies,  and  is  born  dead  be- 
fore the  proper  time.  This  disease  is  so  common  a  cause  of  mis- 
carriage that  when  labor  has  repeatedly  occurred  prematurely  our 
suspicions  should  always  be  excited,  and  we  should  make  inquiries 
as  to  the  previous  health  of  the  parents,  so  that  by  the  proper 
treatment  of  one  or  both,  the  lives  of  succeeding  children  may  be 
preserved. 

If  at  birth,  the  symptoms  are  usually  very  severe.  The  child, 
although  born  alive,  is  emaciated,  and  looks  shrivelled.  He  snuf- 
fles and  cries  hoarsely.     A  few  hours  after  birth,  an  eruption  of 


13-i  INHERITED    SYPHILIS. 

pemphigus  appears,  situated  principally  on  the  palms  and  the  soles 
of  the  feet.  The  bullae  become  filled  with  a  semi-purulent  liquid, 
and  burst,  leaving  angry-looking  sores.  Spots  of  inflammation, 
with  abscesses,  are  scattered  through  the  thymus  gland  and  through 
the  lungs.  The  liver  is  indurated.  The  infant  may  linger  on  for 
a  few  days  or  weeks,  but  these  cases  almost  always  prove  fatal. 

Although  appearing  at  birth,  the  symptoms  are  not,  however, 
always  so  marked  as  those  described.  The  amount  of  flesh  may 
be  considerable,  and  the  lesions  of  the  internal  organs  may  not  be 
present.  In  such  cases  the  child  may  recover,  but  the  prognosis 
is  exceedingly  unfavorable. 

If  after  hirth,  the  child  is  born  apparently  healthy.  He  is  often 
plump,  seems  strong,  and  presents  no  symptoms  by  which  even 
the  most  practised  eye  can  detect  the  disease  lurking  in  his  sys- 
tem. Sometimes,  however,  although  offering  no  distinct  symptoms 
of  disease,  there  is  yet  a  something  which  seems  to  hint  at  the 
approaching  outbreak.  The  face  is  rather  old-looking ;  the  skin 
inelastic  and  unnaturally  pale ;  the  complexion  dull  and  wanting 
in  transparence. 

After  a  time,  varying  from  two  weeks  to  six  or  seven  months, 
although  rarely  after  the  end  of  the  third  month,  evident  symp- 
toms of  the  disease  begin  to  be  observed.  Before  this,  however, 
there  is  one  symptom  which  has  been  little  noticed  by  writers 
upon  this  subject  as  a  sign  of  the  inherited  disease,  but  which  is 
seldom  absent.  This  symptom  is  obstinate  wakefulness  at  night. 
The  child  when  put  to  rest  is  uneasy  and  fretful,  he  cries  almost 
unceasingly,  and  cannot  be  pacified.  During  the  day  he  is  more 
composed,  but  every  night  there  is  a  repetition  of  the  same  disturb- 
ance, and  his  uncontrollable  complaints  are  a  source  of  the  utmost 
perplexity  and  distress  to  his  attendants.  The  crying  is  possibly 
excited  by  nocturnal  pains  in  the  bones  sim.ilar  to  those  affecting 
adults  before  the  outbreak  of  the  constitutional  symptoms.  On 
the  appearance  of  the  rash  the  sleeplessness  does  not  at  once  sub- 
side, but  it  soon  disappears  under  the  influence  of  specific  treat- 
ment. The  outbreak  of  the  general  symptoms  may  be  determined 
by  some  febrile  attack,  as  one  of  the  exanthemata,  the  eruption  of 
which  subsiding  leaves  the  syphilitic  rash  in  its  place.  In  almost 
all  cases  one  of  the  earliest  signs  of  the  disease  is  snuffling.  The 
mother  in  the  beginning  attributes  little  importance  to  this  symp- 
tom, and  indeed  does  not  usually  mention  it  unless  questioned 


SYPHILITIC    RASH.  135 

specially  upon  the  point,  when  she  replies  that  the  child  has  "  had 
a  cold"  for  a  few  days.  Soon  the  mucous  membrane  lining  the 
air-passages  becomes  more  swollen,  but  even  then  there  is  not 
much  snuffling  so  long  as  the  child  breathes  through  his  mouth. 
When,  however,  he  takes  the  breaet,  his  difficulty  of  breathing 
through  the  nose  becomes  at  once  apparent.  Each  inspiration  is 
accompanied  by  a  slight  snore,  and  as  the  obstruction  becomes 
more  decided  he  can  only  suck  at  short  intervals,  desisting  fre- 
quently and  lying  with  the  nipple  in  his  half  open  mouth,  so  as  to 
obtain  a  supply  of  air  before  making  another  effort  to  draw  out 
the  milk.  Occasionally  he  snorts  violently  as  if  in  an  attempt  to 
clear  away  some  obstruction,  and  this  often  causes  serious  alarm 
to  the  mother,  who  will  complain  that  the  child  "  seems  as  if  he 
were  going  to  be  suftbcated  when  he  takes  the  breast." 

After  a  time  there  appears  from  the  nostrils  a  slight  watery  dis- 
charge, which  may  be  tinged  with  blood.  It  is  seldom  profuse  at 
first,  and  is  often  merely  enough  to  give  a  glistening  appearance 
to  the  openings  of  the  nares.  Gradually,  however,  it  becomes  more 
abundant,  and  acquires  consistence,  so  that  it  forms  crusts  which 
block  up  the  nasal  apertures,  and  still  further  impede  the  passage 
of  the  air.  The  discharge  is  intensely  irritating,  and  scalds  the 
parts  with  which  it  comes  in  contact,  producing  cracks  and  little 
ulcerations  about  the  nostrils  and  upper  lip,  which  become  in- 
crusted  with  minute  scabs.  Diday,'  however,  believes  these  ex- 
ternal cracks  and  ulcers  to  be  due  to  mucous  patches,  and  to  be 
independent  of  the  discharge  :  the  discharge  itself  he  attributes  to 
mucous  patches  developed  on  the  Schneiderian  membrane.  In 
severe  cases  the  ulceration  thus  set  up  within  the  nose  may  per- 
forate the  septum  nasi,  or  lay  bare  the  nasal  bones  which  may 
become  necrosed  in  consequence  of  the  exposure.  Fragments  of 
these  bones  are  sometimes  found  in  the  crusts  thrown  off.  The 
bones  may  also  become  loosened  and  sink  down,  so  that  the  bridge 
of  the  nose  is  flattened,  and  looks  broader.  In  rare  cases  snuffling 
is  the  only  symptom  of  the  disease:  sometimes,  but  very  rarely,  it 
is  completely  absent  throughout. 

Soon  after  the  beginning  of  the  coryza,  an  eruption  is  noticed 
on  the  skin.  It  is  usually  first  seen  about  the  anus  and  perineum 
in  the  form  of  flattened,  slightly  elevated  spots,  resembling  very 

•  On  Syphilis  in  New-born  Cliildreu,  by  P.  Diday,  New  Syd.  Soc.  1859. 


136  INHERITED    SYPHILIS. 

much  in  their  color  the  rust  of  iron,  and  which  with  a  lens  may  be 
sometimes  seen  to  be  covered  on  their  surface  with  minute  scales. 
More  usually,  however,  no  scales  are  visible,  for  as  soon  as  formed 
they  are  "  macerated  by  the  natural  moisture  of  the  part,  and  be- 
come detached  before  they  can  acquire,  by  the  evaporation  of  their 
fluid  constituents,  the  pearly  and  brittle  appearance  which  they 
would  assume  in  the  adult.'"  These  spots  are  scattered  over  the 
perineum,  surround  the  anus,  and  speckle  the  scrotum  or  the  labia. 
Sometimes  the  eruption  begins  as  an  erythematous  blush,  at  first 
bright  red,  which  covers  the  buttocks  and  perineum,  and  may 
extend  to  the  lower  part  of  the  belly.  The  color  soon  gets  more 
dingy,  and  has  been  aptly  compared  to  the  lean  of  ham.  It 
becomes  at  the  same  time  distinctly  circumscribed,  ending  at  its 
boundaries  in  an  abrupt  line.  The  colored  surface  is  scaly,  and 
at  its  edges  are  seen  the  rust-colored  spots  before  described.  The 
eruption  is  not  limited  to  these  parts ;  it  often  invades  the  folds  of 
the  joints,  particularly  the  arm-pits,  extends  to  the  sides  of  the 
neck  or  the  chin,  and  may  be  sprinkled  all  over  the  body.  Other 
varieties  of  the  rash  are  also  found,  as  ecthymatous  pustules, 
papules,  tubercular  spots,  mucous  patches;  and  ulcerations,  the 
result  of  these  eruptions,  may  also  be  present. 

"When  ecthyma  is  seen  in  any  quantity,  the  aggregation  of  the 
pustules  presents  a  very  peculiar  appearance,  and  the  general 
aspect  of  a  part  covered  with  such  an  eruption  differs  entirely 
from  that  just  described.  The  eruption  is  usually  seated  on  the 
buttocks  and  perineum,  and  the  pustules  are  more  or  less  closely 
aggregated,  the  color  of  the  part  varying  according  to  the  degree 
to  which  the  pustules  are  separated.  When  crowded  together,  the 
general  tint  is  a  deep  purple — not  uniform,  but  broken  up  into 
patches  of  purple,  separated  by  intervals  where  the  color  is  red. 
When  the  pustules  are  more  widely  apart,  each  one  is  seen  to  con- 
sist of  a  violet-colored  blotch,  crowned  with  a  thick,  blackish  crust, 
and  surrounded  by  a  deep  red  or  copper-colored  areola.  If  placed 
sufficiently  closely,  the  adjacent  areolae  may  join,  so  that  all  of  the 
skin  which  is  seen  between  the  neighboring  pustules  is  of  the  same 
reddish  or  coppery  hue.  The  scabs  cover  an  ulcer,  which  is  apt 
rapidly  to  deepen,  and,  unless  checked,  by  early  treatment,  may 
penetrate  deeply  into  the  tissues,  and  produce  very  serious  results. 

»  Diday,  p.  66. 


MUCOUS    PATCHES.  137 

The  ulcerations  which  arise  from  the  other  forms  of  eruption 
are  often  linear,  and  are  compared  by  Trousseau  to  the  narrow- 
grooves  found  in  worm-eaten  wood.  They  frequently  leave  linear 
cicatrices,  which  may  exist  for  a  long  time  an  evidence  of  the  past 
disease. 

Mucous  patches,  when  they  occur  on  the  skin,  are  seen  as  round 
or  oval  slightly  elevated  patches,  soft,  and  something  of  the  con- 
sistence of  mucous  membrane.  Their  color  is  reddish  or  grayish, 
and  the  surface  is  kept  constantly  moist  by  a  thin,  offensive  secre- 
tion. They  are  usually  found  by  the  side  of  the  anus,  at  the  com- 
missures of  the  lips,  about  the  genitals,  between  the  fingers  and 
toes,  or  anywhere  else  where  the  skin  is  especially  delicate  and 
moist.  AVhen  they  occur  on  the  mucous  membranes,  they  are 
described  by  Diday  as  irregularly-rounded  white  elevations,  in  the 
centre  of  which  a  point  of  excavation  shows  itself:  this  spreads,  so 
that  after  a  very  short  time  only  a  single  ulcer  is  observed.  It  is 
not  uncommon  to  find  them  on  the  arches  of  the  fauces,  but  they 
never  exist,  according  to  Trousseau,  at  the  back  of  the  pharynx. 
Still,  on  account  of  the  difficulty  often  experienced  in  obtaining  a 
good  view  of  the  back  of  the  throat  in  a  child,  we  can  seldom  be 
sure  that  there  are  no  lesions  on  the  posterior  wall  of  the  pharynx. 

The  skin  of  a  syphilitic  child  is  dry  and  parchment-like,  and  is 
often  scaly,  especially  on  the  palms  of  the  hands  and  the  soles  of 
the  feet.  Fissures  are  often  seen  between  the  fingers  and  toes,  and 
may  be  found  radiating  from  the  anus  and  the  corners  of  the 
mouth,  and  at  the  commissures  of  the  eyelids. 

A  kind  of  whitlow  is  occasionally  present  from  specific  inflam- 
mation and  suppuration  of  the  matrix  of  the  nail.  The  nutrition 
of  the  nail  thus  interfered  with,  it  gets  dry,  and  falls  off.  M. 
Bouchut^  states  that  he  has  seen  a  case  in  which  every  nail,  both 
on  the  fingers  and  on  the  toes,  was  thus  affected. 

The  hairs  of  the  eyelashes  and  eyebrows  often  fall  out:  the 
edges  of  the  eyelids  then  become  scaly.  The  color  of  the  face  is 
yellowish,  and  has  been  compared  by  Sir  W.  Jenner  to  the  color 
of  weak  cafe-au-lait.  It  is  different  from  the  earthy  tinge  often 
seen  in  chronic  diarrhoea,  and  must  not  be  confounded  with  it. 
This  tint  does  not  spread  to  the  rest  of  the  body,  but  remains 
limited  to  the  face,  where  it  is  most  marked  on  the  more  prominent 

'  Maladies  des  Nouveaux-nes.     Paris,  1862. 


138  INHERITED    SYPHILIS. 

parts,  being  less  noticeable  on  the  deeper  parts,  as  the  internal 
angle  of  the  orbit,  and  the  hollow  of  the  lower  lip.  Besides  this 
peculiar  tint  of  the  face,  there  is  a  very  striking  pallor  of  the  body 
generally,  which  is  very  slow  to  disappear,  even  after  the  sub- 
sidence of  the  other  symptoms. 

The  cry  of  the  infant  is  one  of  the  most  noticeable  features  of 
the  disease ;  it  is  hoarse  and  high  pitched,  and  when  once  heard  is 
not  difficult  to  recognize  again.  Its  peculiar  quality  is,  no  doubt, 
due  to  an  extension  of  the  mucous  patches  to  the  larynx.  In  one 
case  which  came  under  the  author's  notice,  a  child  of  five  weeks 
old,  the  hoarseness  was  accompanied  by  attacks  of  laryngismus 
stridulus. 

As  a  rule  the  fontanelle  in  children  suffering  from  this  disease 
is  very  widely  open.  It  appears  as  if  the  cachexia  exercised  some 
influence  in  retarding  ossification  of  the  bones.  Strangely  enough, 
however,  the  growth  and  development  of  the  teeth  do  not  appear 
to  suffer ;  indeed  the  contrary  is  found  to  be  the  case,  for  the  teeth 
are  often  cut  very  early,  and  with  remarkable  ease.  It  is  not 
uncommon  to  see  the  front  teeth  appear  while  the  body  is  yet 
covered  with  the  syphilitic  rash. 

Besides  the  above  symptoms,  nodes  of  the  long  bones  may  be 
present,  and  indurated  deposits  may  occur  in  the  areolar  tissue, 
tendons,  and  muscles.  The  posterior  cervical  glands  are  often 
enlarged.     Iritis  may  also  occur. 

The  general  condition  of  the  infant  varies,  not  according  to  the 
severity  of  any  particular  symptom,  but  according  to  the  intensity 
of  the  general  cachexia.  The  child  sometimes  continues  plump, 
and  although  pale  and  rather  weak,  yet  seems  to  suffer  compara- 
tively little  from  the  effects  of  the  disease.  In  other  cases  he 
wastes  and  becomes  very  feeble ;  his  face,  owing  to  the  inelasticity 
of  the  skin,  becomes  wrinkled  like  that  of  an  old  man ;  he  is 
peevish  and  cries  constantly,  never  seeming  to  rest  night  nor  day. 
His  difficulty  in  taking  the  breast  increases  his  irritability,  and  the 
consequent  want  of  nourishment,  his  weakness.  He  dwindles 
rapidly;  vomiting  or  diarrhoea  may  come  on  to  increase  his  pros- 
tration, and  he  dies  either  suddenly  from  syncope,  or  slowly  from 
exhaustion. 

According  to  Mr.  Hutchison,'  such  children  are  especially  liable 

'  Reynolds'  System  of  MeiUcine,  vol.  i.  art.  Syphilis. 


DISEASE    OF    LIVER.  139 

to  serous  inflammations,  and  pleurisy  is  a  not  uncommon  cause  of 
death.  Pneumonia  in  syphilitic  infants  is  not,  however,  a  specially 
fatal  disease.  The  inflammation  may  in  them  run  as  short  a 
course,  and  the  deposit  may  clear  away  as  completely  as  in  chil- 
dren of  healthy  constitution. 

AJfedions  of  the  internal  organs. — Suppurations  of  the  thymus 
gland  and  of  the  lungs  have  already  been  mentioned  as  occurring 
in  new-born  children  in  whom  the  disease  appears  at,  or  a  few 
days  after,  birth.  Besides  these  organs,  the  liver,  spleen,  and  peri- 
toneum are  sometimes  affected. 

The  liver  is  hypertrophied  and  indurated  either  generally  or 
partially,  the  enlargement  being  sometimes  confined  to  one  lobe, 
or  to  a  part  of  one  lobe.  Where  it  occurs  it  is  one  of  the  earliest 
signs  of  the  disease,  and  usually  causes  death  in  a  few  daj'^s.  The 
symptoms  which  mark  its  presence  are — besides  the  enlargement 
— pain  in  the  belly,  shown  by  moaning  and  uneasy  movements  of 
the  limbs,  vomiting,  and  diarrhoea,  or  constipation.  The  abdomen 
is  tympanitic  and  tender  on  pressure ;  the  pulse  quick  and  small ; 
the  expression  of  the  countenance  is  altered,  and  the  features  look 
pinched  and  drawn.  There  is  rarely  any  jaundice.  Sometimes 
the  pressure  of  the  enlarged  liver  upon  the  vena  cava  may  pro- 
duce extensive  oedema  of  the  lower  limbs,  and  of  the  scrotum. 
This  was  seen  by  the  author  in  a  case  in  which  the  syphilitic 
symptoms  appeared  a  fortnight  after  birth.  There  was  obstinate 
constipation,  and  vomiting,  and  the  mucous  membrane  of  the 
mouth  was  covered  with  thrush.  The  heart  and  lungs  were 
healthy.  The  infant  rapidly  sank  and  died.  Gubler,*  who  first 
drew  attention  to  this  condition  of  the  liver  as  a  result  of  S3'-philis, 
describes  the  organ  in  highly  marked  cases  as  hypertrophied, 
globular,  hard,  and  elastic.  It  is  extremely  resistant  to  pressure 
and  creaks  under  the  knife  when  cut  into.  On  section  the  natural 
appearance  of  the  surface  is  seen  to  be  quite  lost,  and  in  its  stead 
we  see  layers  of  small,  white,  opaque  grains  on  a  yellowish  uniform 
ground.  No  blood,  but  only  a  little  yellowish  serum,  escapes  on 
pressure.  The  capillary  vessels  are  obliterated,  and  the  calibre  of 
the  larger  vessels  is  considerably  diminished.  These  changes  are 
due  to  the  development  of  large  quantities  of  fibro-plastic  tissue 

'  Gaz.  des  Hupitaux,  18i8,  Jan.     Gaz.  Med.,  1852,  p.  262. 


l-iO  INHERITED    SYPHILIS. 

which  compresses  the  hepatic  cells,  obliterates  the  vessels,  and 
consequently  prevents  the  secretion  of  bile  in  the  parts  so  affected. 

Local  peritonitis  often  accompanies  this  conditition  of  the  liver. 
Whether  it  is  a  consequence  of  the  induration,  or  may  occur 
independently  of  the  hepatic  lesion,  is  a  question  which  remains 
undecided. 

Enlargement  of  the  spleen  in  this  disease  was  noticed  first  by 
Dr.  Samuel  Gree,  who  embodied  the  results  of  his  researches  in  a 
paper  read  before  the  Medico-Chirurgical  Society,  March  26, 1867.^ 
Dr.  Gree  states,  that  "  in  about  one-half  of  the  cases  of  hereditary 
syphilis  the  spleen  is  enlarged,  so  that  it  can  be  felt  during  life. 
In  about  one-fourth  the  enlargement  is  really  great.  Sometimes 
the  spleen  only  is  enlarged ;  sometimes  enlargement  of  the  liver 
or  lymphatic  glands  is  superadded.  The  majority  of  cases  of  great 
enlargement  die ;  yet  syphilitic  children  with  a  greatly  enlarged 
spleen  may  recover;  the  spleen  gradually  diminishing  in  size  as 
the  health  improves.  The  degree  of  the  splenic  enlargement 
may  be  taken  as  an  index  of  the  severity  of  the  cachexia,  with 
this  qualification,  viz.,  that  the  spleen  does  not  diminish  jJCf^'i-J^assu 
with  the  cachexia,  but  remains,  it  may  be  for  years,  a  monument 
of  what  the  cachexia  has  been.  Hence,  in  children  of  three  years 
pld  and  upwards,  who  bear  the  marks  of  past  syphilis  upon  them, 
we  can  often  feel  the  spleen  enlarged.  Still  more  interesting  and 
important  is  the  fact  that  an  enlarged  spleen  is  sometimes  the  only 
sign  of  an  active  syphilitic  cachexia. 

These  affections  of  the  internal  organs  do  not  seem  to  stand  in 
any  direct  relation  to  the  general  symptoms.  In  cases  where  the 
latter  are  very  severe,  and  the  influence  of  the  disease  upon 
nutrition  is  most  powerfully  manifested,  the  liver  and  spleen  may 
present  no  sign  of  pathological  change.  In  other  cases,  again, 
these  organs  may  suffer  severely,  while  the  external  characters  of 
the  disease  are  but  faintly  marked. 

In  rare  cases  the  symptoms  of  hereditary  syphilis  are  delayed 
until  the  seventh,  ninth,  tenth,  or  even  fourteenth  year.  Coppery, 
scaly,  eruptions  may  then  appear,  with  discharges  from  the  ears, 
nose,  &c.  Chronic  interstitial  keratitis  may  also  occur  at  these 
times.     This  disease  has  been  described  by  Mr.  Hutchinson;^  it 

•  An  abstract  of  this  valuable  paper  appeared  in  the  "  Lancet"  for  April  13, 1867. 
'  Clinical   Memoir  on   Certain  Diseases  of  the  Eye   and  Ear  Consequent  on 
Inherited  Syphilis.     1862. 


DIAGNOSIS.  141 

is  not  very  common,  but  when  it  does  occur,  is  symptomatic  of 
hereditary  syphilis.  A  peculiar  malformation  of  the  teeth  is  also 
sometimes  found,  for  our  knowledge  of  which  we  are  indebted  to 
the  same  author.  This  malformation  affects  only  the  permanent 
teeth,  and  is  usually  limited  to  the  upper  incisors.  The  upper 
central  incisors  are  narrow  and  short.  On  account  of  the  dwarf- 
ing they  do  not  touch,  and  spaces  are  consequently  left  in  the  gum 
on  each  side.  At  the  same  time  the  edges  are  uneven  from 
atrophy  of  the  middle  lobe,  so  that  a  broad,  vertical  notch  is  thus 
left  in  the  centre  of  the  edge,  from  which  a  shallow  furrow  or 
groove  may  pass  backwards  on  both  anterior  and  posterior  surfaces 
nearly  to  the  gum.  The  notching  is  usually  symmetrical,  but  not 
always,  for  sometimes  only  one  tooth  is  affected. 

These  symptoms  may  be  found,  not  only  when  the  disease  is 
thus  deferred,  but  also  when  it  has  appeared  at  the  ordinary  time 
during  infancy.     They  constitute  the  tertiary  stage. 

Relapses  are  very  liable  to  occur  in  children  after  the  cessation 
of  all  symptoms,  and  when  the  disease  is  supposed  to  be  cured. 
The  most  common  form  is  the  appearance  of  mucous  patches, 
with  large  thickened  elevated  edges,  seated  by  the  side  of  the  anus, 
at  the  angle  of  the  mouth,  on  the  tongue,  or  between  the  fingers 
and  toes.  The  coppery  eruption  may  also  return,  but  not  usually 
to  any  great  extent. 

Diagnosis. — In  a  well-marked  case,  the  wizened  face,  the  snuffling, 
the  peculiar  complexion,  the  hoarse  cry,  the  emaciation,  the  dry 
and  parchment-like  skin,  with  the  characteristic  eruption  scattered 
over  the  surface,  the  fissured  lips  and  anus,  form  a  collection  of 
symptoms  which  when  once  seen  it  is  impossible  afterwards  to 
mistake.  We,  however,  constantly  find  cases  in  which  many  of 
the  symptoms  are  absent.  The  child  may  continue  plump,  and 
be  apparently  in  good  condition  ;  but  here  there  is  usually  snufiiing; 
rust-colored  spots  are  found  about  the  perineum,  and  fissures  will 
be  seen  radiating  from  the  anus,  and  perhaps  from  the  corners  of 
the  mouth.  The  general  pallor  of  the  skin  is  seldom  absent, 
although  the  special  "  cafe-au-laif  tint  of  the  complexion  may  not 
be  noticed.  The  deep  purple  tint  produced  by  a  collection  of 
ecthymatous  pustules,  presents  a  very  characteristic  appearance,  and 
one  which  it  is  difficult  to  mistake,  especially  when  it  is  combined 
with  the  cracks  and  ulcerations  about  the  anus,  &c.  The  appear- 
ance alone  of  ecthyma  in   an  infant  should  lead  us  to  suspect 


142  INHERITED    SYPHILIS. 

syphilis.  Scabies  is  the  ooly  other  cause  which  is  found  to  pro- 
duce such  pustules  at  this  early  age,  and  this  is  at  once  detected  by 
the  absence  of  other  signs  of  syphilis,  by  the  fewer  number  of  the 
pustules,  and  by  the  presence  of  the  characteristic  furrow  peculiar 
to  the  acarus.  Sometimes  snuffling  is  the  only  symptom  which 
marks  the  existence  of  syphilis.  In  these  cases  the  diagnosis  is 
more  uncertain,  but  a  careful  examination  will  often  detect  a  few — 
perhaps  only  one  or  two — rusty  spots  about  the  body;  if  not,  and 
the  snuffling  continues  two  or  three  weeks,  specific  treatment 
should  be  always  had  recourse  to,  for  obstinate  coryza  is  commonly 
due  to  a  syphilitic  taint. 

If  in  doubt  in  any  case,  after  a  careful  examination  of  the  child's 
whole  body,  we  should  inquire  into  the  health  of  the  other  chil- 
dren, examine  them  for  signs  of  past  disease,  and  question  the 
parents  as  to  their  own  health,  especially  as  to  the  occurrence  of 
previous  miscarriages  on  the  part  of  the  mother. 

The  signs  of  past  disease  in  the  child  are :  flattened  bridge  of 
the  nose,  from  long-continued  swelling  of  the  nasal  mucous-mem- 
brane when  the  bones  are  soft ;  markings  of  the  skin  by  little  pits, 
or  linear  cicatrices,  from  former  ulceration,  especially  about  the 
angles  of  the  mouth;  and  protuberant  forehead,  from  infantile 
arachnitis.^  To  these  may  be  added  enlarged  spleen,  which  is 
found,  according  to  Dr.  Gee,^  long  after  the  disappearance  of  the 
other  symptoms.  If  the  permanent  teeth  have  appeared,  the 
incisors  should  be  examined  for  malformations. 

Causes. — The  disease  may  be  transmitted  from  parents  to  chil- 
dren through  the  influence  of  either  the  father  or  the  mother.  In 
the  child  the  degree  of  severity  of  the  inherited  taint  is  in  propor- 
tion to  the  shortness  of  the  time  which  has  elapsed  since  the  ap- 
pearance of  the  primary  symptoms  in  the  parent.  The  father 
alone  may  be  suffering  from  the  disease,  and  may  impart  the  taint 
to  the  child,  according  to  some  authors,  without  at  the  same  time 
infecting  the  mother.  The  mother,  however,  seldom  seems  to 
escape  the  effects  of  the  virus,  whether  it  is  that  she  absorbs  the 
poison  from  the  infected  ovum,  or  contracts  the  disease  from  her 
husband.  In  all  cases  of  supposed  exemption  from  the  disease  occur- 
ring in  women  who  have  borne  syphiltic  children,  a  careful  exami- 

'  On  Syphilis,  by  J.  Hutchinson,  in  Reynolds'  System  of  Medicine,  vol.  i. 
2  Loc.  cit. 


TWINS  SOMETIMES  EQUALLY  AFFECTED.      143 

nation  of  the  whole  body  would  no  doubt  enable  us  to  detect  some 
signs  of  the  disease.  Colles,'  in  his  work  on  syphilis,  lays  down 
the  law  that  "a  new-born  child  affected  with  congenital  syphilis, 
even  although  it  may  have  symptoms  in  the  mouth,  never  causes 
ulceration  of  the  breast  which  it  sucks,  if  it  be  the  mother  who 
suckles  it,  though  continuing  capable  of  infecting  a  strange  nurse." 
This  is  a  very  strong  argument  against  the  escape  of  the  mother 
under  such  circumstances,  for  to  be  incapable  of  infection  by  the 
child  she  must  be  herself  a  subject  of  the  disease.  Various  cases 
of  apparent  exception  to  this  rule  have  been  published,  but  none 
of  them  will  bear  the  test  of  careful  examination. 

The  mother  alone  may  be  syphilitic.  These  cases  occur  where 
a  widow,  infected  by  her  deceased  husband,  marries  in  second  nup- 
tials a  healthy  man,  and  bears  a  diseased  child  ;  or  where  a  healthy 
woman  married  to  a  healthy  man,  suckles  a  syphilitic  child,  con- 
tracts the  disease  from  it,  and  at  her  next  confinement  bears  a  syphi- 
litic infant.  Even  if  the  mother  be  healthy  at  the  time  of  the 
impregnation  of  the  ovum,  the  child  may  still  be  born  diseased, 
provided  that  the  mother  contracts  the  disorder  after  the  fourth 
week,  and  before  the  completion  of  the  seventh  month  of  preg- 
nancy. Before  the  fourth  week  the  embryo  is  nourished  by  imbi- 
bition, growing  at  the  expense  of  the  albuminous  matters  by  which 
it  is  surrounded,  and  of  the  vitelline  membrane ;  after  the  seventh 
month  it  is  also  leading  a  comparativelj'^  separate  existence. 

In  cases  where  the  father  alone,  or  the  mother  alone,  is  syphilitic, 
the  child  is  sometimes  found  to  escape  contamination,  and  to  be 
born  free  from  the  disease.  Where,  however,  both  parents  are 
infected,  the  infant's  chances  of  escape  become  very  much  lessened, 
and  he  usually  suffers  severely  from  the  inherited  taint. 

In  the  case  of  twins  born  of  parents  the  subjects  of  this  disease, 
the  two  children  are  not  necessarily  affected  to  an  equal  degree. 

Thus,  "  Minnie  H ,  aged  three  months,  very  much  emaciated, 

being  according  to  the  mother's  account,  smaller  than  at  birth. 
Snuffles,  and  has  snuffled  since  she  was  born.  Skin  shrivelled  and 
parchment-like,  covered  with  pemphigus."  Under  treatment,  the 
spots  disappeared,  and  the  child  at  first  seemed  improving,  but  she 
afterwards  sank,  and  died,  having  persistently  wasted  since  birth. 

The  second  twin  was  seen  on  the  day  the  first  died.     "  A  very 

■  On  the  Venereal  Disease.     1837. 


14i  INHERITED    SYPHILIS. 

healthy-looking  child,  with  good  complexion,  fat  and  vigorous. 
She  has  snuffled  since  birth,  and  on  the  buttocks  are  seen  stains 
left  by  recent  eruption.  Was  never  thought  sufficiently  ill  to 
require  medical  advice." 

These  two  cases  of  twins  suffering  from  the  same  hereditary 
disease  are  very  interesting,  as  showing  that  the  amount  of  disease 
inherited  by  the  foetus  in  the  womb  is  not  determined  solely  by  the 
amount  of  disease  from  which  the  parents  may  be  suffering  at  the 
time.  Some  other  causes  must  also  operate.  In  the  case  of  twins 
born  of  healthy  parents,  we  often  find  one  to  be  more  vigorous 
than  the  other,  and  it  often  happens  that  one  will  sink  and  die 
while  the  other  remains  strong  and  robust.  So  in  the  case  of  the 
inheritance  of  a  constitutional  disease,  if  the  twins  are,  while  in  the 
womb,  of  unequal  vigor,  the  one  drawing  to  itself  a  greater  pro- 
portion of  nutritive  material  than  the  other,  the  less  vigorous  foetus 
would  no  doubt  have  a  less  degree  of  resisting  power,  and  would 
suffer  to  a  greater  extent  than  the  other  from  the  effects  of  a 
poison  to  which  both  are  equally  exposed. 

When  the  child  is  born  perfectly  healthy  he  may  still  be  infected 
after  birth.  He  may  contract  the  disease  during  lactation,  the 
nipple  of  the  mother  or  nurse  having  become  the  seat  of  a  syphi- 
litic sore  from  contact  with  the  mouth  of  another  child  who  is 
suffering  from  the  disease.  Whether  the  milk  of  a  syphilitic 
woman  is  capable  alone  of  communicating  the  disease  to  a  healthy 
child  is  open  to  very  considerable  doubt.  Again,  accidental  con- 
tact with  purulent  matter  from  a  chancre,  or  with  discharges  from 
a  secondary  sore,  may  inoculate  the  child,  each  of  these  secretions 
producing  its  own  particular  effect  upon  the  infant,  a  primary  sore 
producing  a  primary  sore,  and  a  secondary  sore  a  secondary  sore. 

With  regard  to  the  possibility  of  syphilitic  inoculation  by  vacci- 
nation, which  was  long  denied,  it  seems  probable  from  instances 
published  by  Chassagnac,'  Devergie,^  Pacchiotti,^  Nayler,^  and 
others,  that  infection  by  this  means  may  occasionally  take  place. 
Every  case,  however,  in  which  the  symptoms  appear  after  vacci- 
nation must  not  be  necessarily  attributed  to  inoculation  by  tainted 
lymph.     The  first  manifestation  of  the  latent  disease  may  be  de- 

'  Journ,  f.  Kinderk.  xliv.     1865. 

2  Ibid.  vi.     1866. 

3  Oaz.  della  Assoc.  Med.     1865. 

*  Sritish  Medical  Journal.     1866. 


PROGNOSIS,  145 

termined  by  anything  which  sets  up  a  temporary  febrile  disturb- 
ance, and  vaccination  therefore  may,  like  other  things,  be  the 
stimulus  exciting  the  outbreak  of  previously  existing  disease. 

Direct  inoculation  by  a  primary  sore  in  the  vagina  during  de- 
livery, although  possible,  is  not  probable,  and  no  well-authenticated 
instance  of  such  inoculation  having  occurred  has  been  recorded. 

Prognosis. — Indications  derived  from  ohservation  of  the  2^c(,rents. — 
As  a  rule  the  prognosis  becomes  more  favorable  with  each  suc- 
ceeding pregnancy,  the  tendency  of  the  poison  being  to  become 
less  and  less  noxious  as  years  pass  by.  This  rule,  however,  is  not 
absolute.  Cases  occasionally  occur  where  the  opposite  conditions 
are  found.  Thus,  if  the  father  be  syphilitic,  and  the  mother,  at  the 
time  of  marriage,  be  perfectly  healthy,  in  each  succeeding  preg- 
nancy the  fcetus  becomes  not  unfrequently  more  and  more  pro- 
foundly contaminated,  for  in  these  cases  the  healthy  mother  may 
contract  the  disease  from  the  tainted  infant  she  carries  in  her 
womb.  Consequently  the  greater  the  number  of  the  previous  preg- 
nancies the  more  thoroughly  is  her  system  likely  to  be  infected  by 
the  poison,  and  the  more  thoroughly  will  she  communicate  it  to 
her  offspring.  Again,  a  man  who  has  contracted  the  disease  before 
marriage,  and  has  undergone  suitable  treatment,  may  at  first  beget 
a  perfectly  healthy  child.  Afterwards,  however,  although  no  fresh 
symptoms  may  have  appeared  in  the  interval,  he  may  beget  other 
children  who  are  syphilitic.  These  cases,  of  which  well-authenti- 
cated instances  are  recorded,  are  explaine'd  by  supposing  that  the 
treatment  to  which  he  was  subjected  "  had  for  the  time  a  suffici- 
ently potent  effect  to  maintain  the  seminal  fluid  in  good  condition, 
and  that  it  had  afterwards  resumed  its  venereal  character  in  pro- 
portion as  the  effects  of  the  treatment  became  lessened  by  time.'" 

Still,  if  we  find  a  woman  bearing  children,  at  first  prematurely 
then  still-born  at  the  full  time,  afterwards  living  but  diseased,  and 
still  later  producing  children  who  present  at  first  all  the  appear- 
ances of  health,  although  carrying  in  them  the  germs  of  disease  to 
be  developed  after  a  few  weeks  or  months,  we  may  reasonably 
infer  that  the  poison  is  wearing  itself  out,  and  that  each  succeeding 
infant  has  a  better  chance  than  its  predecessor  of  outliving  the 
disease.  As  a  rule,  the  longer  the  time  which  elapses  between  the 
birth  of  a  child  and  the  appearance  of  the  first  symptoms  the 

Diday. 

10 


146  INHERITED    SYPHILIS. 

greater  is  the  likelihood  of  his  recovery.  According  to  Trousseau, 
the  disease  is  almost  always  fatal  when  the  symptoms  appear 
during  the  first  two  weeks  of  life. 

Indications  derived  from  observation  of  the  child. — It  is  to  the 
intensity  of  the  general  cachexia,  and  not  to  the  severity  of  any 
particular  symptom,  that  we  must  look  in  order  to  estimate  the 
amount  of  danger  in  each  case.  The  prognosis  is  serious  in  pro- 
portion to  the  degree  to  which  nutrition  is  interfered  with,  and 
therefore  anything  which  tends  to  increase  this  defect  in  nutrition 
tends  greatly  to  increase  the  gravity  of  the  case.  Thus  vomiting 
and  diarrhoea  add  their  own  enfeebling  effects  to  the  general 
weakeneng  influence  of  the  original  disease,  and,  where  they  occur, 
must  be  looked  upon  as  very  serious  complications. 

There  is,  however,  one  special  symptom  which  it  is  very  import- 
ant to  take  into  consideration  in  forming  a  prognosis,  as  it  may 
indirectly  produce  very  serious  results.  This  is  the  condition  of 
the  nasal  passages.  These  passages  may  become  completely 
blocked  up,  partly  by  the  swelling  of  the  Schneiderian  membrane, 
partly  by  the  caking  of  the  crusts  formed  by  the  dried  discharge. 
Two  dangers  may  arise  from  this  source.  As  air  can  no  longer 
pass  through  the  nose,  the  mouth  becomes  the  only  channel  by 
which  air  can  be  admitted  into  the  lungs.  It  is  therefore  required 
for  respiration,  and  cannot  be  spared  for  any  other  purpose.  The 
child  is  consequently  prevented  almost  entirely  from  taking  nou- 
rishment, for  while  he*  sucks,  respiration  has  necessarily  to  be 
suspended.  He  can  only  take  the  breast  by  short  snatches,  and 
the  amount  of  milk  he  receives  is  very  inadequate  to  his  wants. 
The  danger  of  starvation  is  thus  added  to  the  other  dangers  of  the 
case,  and  may  exercise  a  very  unfavorable  influence  upon  the  ter- 
mination of  the  disease.  A  second  danger  resulting  from  the 
condition  of  the  nose  is  that  arising  from  absorption  of  the  noxious 
gases  produced  by  decomposition  of  the  pent-up  pus.  Septicaemia 
may  occur  in  this  way. 

On  the  whole,  we  may  conclude  that  if  nutrition  appears  to  be 
well  performed,  i.e.,  if  the  child  continues  plump,  or  does  not  sensi- 
bly emaciate,  the  prognosis  is  favorable.  If  he  wastes,  the  prognosis 
is  highly  unfavorable. 

Prevention. — When  a  child  is  born  sufiferiug  from  syphilis, 
measures  should  always  be  adopted  to  prevent  succeeding  children 
falling  victims  to  the  same  disease.     One  or  both  parents  should 

f 


TREATMENT.  147 

be  subjected  to  suitable  treatment,  which  should  be  continued 
sufficiently  long  to  render  it  probable  that  the  next  child  will 
escape  the  effects  of  the  virus.  Even  if  a  second  pregnancy  have 
already  occurred  before  any  treatment  is  adopted,  we  should  still 
not  despair,  for  cases  are  recorded  which  show  that  very  favorable 
results  may  be  obtained  by  this  means.  It  is  important,  however, 
that  the  treatment  be  begun  as  early  as  possible,  and  be  continued, 
if  it  can  be  borne,  for  three  full  months. 

Treatment. — In  the  treatment  of  syphilitic  children  we  have  two 
objects.  We  have  to  destroy  the  cachexia  which  is  weighing  upon 
the  child,  and  we  have  to  sustain,  and  if  possible  to  improve,  the 
general  nutrition  of  the  body.  The  second  of  these  objects  is  to 
some  extent  effected  by  the  same  means  which  accomplishes  the 
first.  As  the  intensity  of  the  cachexia  diminishes,  nutrition  usually 
improves  in  equal  proportion ;  and,  therefore,  in  the  milder  cases  a 
child  is  often  found,  as  the  sj^mptoms  disappear,  to  become  strong 
and  healthy  under  no  other  treatment  than  that  required  for  attack- 
ing the  transmitted  taint.  In  the  severer  cases,  however,  nutrition 
is  so  lowered  that  special  means  must  be  adopted  at  once  to 
neutralize  the  effects  and  to  remove  the  cause,  of  his  malnutrition. 

Treatment  must  be  begun  directly  any  symptoms  appear  to 
indicate  the  disease  from  which  the  infant  is  suffering.  If  the 
previous  children  have  been  syphilitic,  and  the  parents  in  the 
interval  have  been  subject  to  no  treatment,  the  child  should  at 
once  be  placed  under  the  influence  of  remedies,  even  although  he 
may  at  the  time  present  no  symptoms  of  the  disease,  for  it  is  of 
the  highest  importance  that  treatment  should  commence  before  the 
cachexia  has  produced  any  marked  impairment  of  the  nutrition  of 
the  body.  If  the  parents  have  undergone  treatment  in  the  inter- 
val, a  careful  watch  should  be  kept  over  the  infant,  and  the  first 
sign  of  the  disease  should  be  the  signal  for  active  interference. 

Whatever  opinions  may  be  held  with  regard  to  the  mercurial 
or  non-mercurial  treatment  of  syphilis  in  the  adult,  in  the  child 
there  is  not  so  much  room  for  hesitation.  As  the  danger  of  the 
disease  lies  in  the  intensity  of  the  cachexia,  as  the  prognosis  is 
favorable  in  proportion  to  the  time  which  has  elapsed  before  the 
appearance  of  the  first  symptoms,  a  remedy  which  has  the  effect 
of  weakening  the  power  of  the  cachexia,  and  therefore  of  delaying 
the  outbreak  of  the  symptoms,  is  not  one  to  be  lightly  disregarded. 
Such   delay    may  make   all   the    difference    between    death    and 

f 


148  INHERITED    SYPHILIS. 

recovery,  for  to  retard  the  appearance  of  the  symptoms  is  in  many 
cases  to  save  the  life  of  the  child.  A  non-mercurial  treatment  is 
still,  however,  advocated  by  some  writers ;  such  treatment  consist- 
ing in  the  administration  of  chlorate  of  potash  with  dilute  hydro- 
chloric acid  and  of  cod-liver  oil,  in  attention  to  diet  and  cleanli- 
ness, and  in  insuring  a  plentiful  supply  of  fresh  air,  in  endeavor- 
ing, in  fact,  without  special  treatment,  to  counteract  the  depressing- 
influence  of  the  cachexia  upon  nutrition,  and  by  invigorating  as 
much  as  possible  the  strength  of  the  system,  to  enable  it  to  over- 
power the  constitutional  poison,  and  prevent  this  from  manifesting 
its  existence.  Such  treatment,  when  the  taint  is  comparatively 
weak,  is  no  doubt  frequently  successful.  The  disease  is'for  the 
time  kept  under,  and  in  every  recurrence  of  the  symptoms  the 
danger  is  tided  over  by  the  same  means.  Cases,  however,  occur 
where  this  plan  is  quite  ineffectual ;  and  in  severe  cases,  where  the 
contamination  of  the  system  is  profound,  and  the  danger  to  life 
imminent,  it  is  surely  unwise  to  neglect  an  agent  which  has  so 
marked  an  influence  on  the  disease.  The  power  of  the  mineral 
over  the  cachexia  is  conclusively  proved,  as  Diday  points  out,  by 
its  influence  upon  the  mother  during  pregnancy.  She  is  enabled 
by  this  means  to  bear  a  healthy  child,  although  all  her  previous 
children  may  have  been  deeply  infected.  Besides,  the  rapidity 
with  which  syphilitic  symptoms  in  the  child  will  disappear  under 
its  use  must  be  familiar  to  every  one  accustomed  to  infantile 
diseases. 

The  child  may  be  treated  indirectly  through  the  mother,  or  by 
the  administration  of  remedies  directly  to  himself.  If  the  mother 
is  suckling  her  infant,  the  first  method  is  valuable  as  oft'ering  a 
suitable  means  for  the  simultaneous  treatment  of  both  mother  and 
child.  For  the  infant,  too,  it  has  this  special  advantage,  that  treat- 
ment bv  the  medicated  milk  is  less  likely  to  cause  irritation  of  his 
digestive  organs — an  occurrence  of  all  things  to  be  avoided.  Be- 
sides, the  remedy  reaching  the  stomach  in  frequent  small  doses, 
and  at  a  time  when  that  organ  is  actively  employed  in  the  work 
of  digestion,  finds  at  once  ready  admission  into  the  system.  M. 
Bouchut  urges  the  employment  of  this  method  in  all  cases  as  the 
most  efficient  and  the  safest  way  of  treating  the  disease.  In  mild 
cases  this  mode  of  treatment  will,  no  doubt,  be  sufficient  to  effect  a 
cure,  but  more  commonly  we  find  it  necessary  in  addi<^ion  to  give 
mercury  to  the  child.     It  often  happens  that  the  secretion  of  milk 


TREATMENT  BY  MERCURY.  149 

in  the  diseased  mother  is  so  scanty,  and  so  poor  in  quality,  that  the 
amount  of  the  drug  which  reaches  the  infant  by  this  means  is 
quite  insufficient  to  produce  any  marked  result ;  and  in  those  cases 
where  the  child  is  much  emaciated,  and  where  it  is  important  to 
bring  him  as  rapidly  as  possible  under  the  influence  of  the  remedy, 
it  is  of  comparatively  little  value  unless  aided  by  the  direct  method 
of  treatment. 

In  giving  mercury  directly  to  the  child,  the  preparation  which 
is  most  commonly  employed  in  this  country  is  the  ordinary 
hydrargyrum  cum  creta.  Of  this,  one  grain  may  be  given  at  first 
every  morning  and  evening.  After  the  first  week  the  dose  should 
be  gradually  increased  every  three  days  by  a  quarter  of  a 
grain  at  a  time,  until  two  grains  are  taken  twice  a  day.  To  pre- 
vent any  irritating  action  on  the  alimentary  canal,  a  grain  of  car- 
bonate of  potash,  or  a  few  grains  of  prepared  chalk,  may  be  added 
to  each  dose.  If,  in  spite  of  this  addition,  any  disturbance  of  the 
stomach  or  bowels  be  excited  by  the  drug,  the  remedy  should  be 
omitted  for  a  day  or  two  until  this  derangement  has  subsided ;  it 
must  then  be  recommenced.  Should  the  disturbance  return,  the 
gray  powder  must  be  changed  for  one  of  the  other  preparations  of 
mercury.  A  solution  of  corrosive  sublimate  in  syrup  is  strongly 
recommended  by  French  authors.  Of  this,  Diday  orders  one-tenth 
of  a  grain  to  be  given  in  (three)  divided  doses  in  the  four-and- 
twenty  hours,  and  to  be  increased  by  one-twentieth  of  a  grain 
every  three  days  until  "  some  sensible  effect  is  produced  either  on 
the  mouth  or  on  the  syphilitic  symptoms."^  Calomel  in  doses  of 
from  one-twelfth  to  one-sixth  of  a  grain  is  sometimes  employed, 
and  where  vomiting  has  been  excited  by  the  other  preparations, 
is  occasionally  effectual  in  calming  the  irritability  of  the  sto- 
mach; but  it  is  itself  liable  to  be  attended  with  ^iarrhoea,  and 
can  seldom  be  continued  long  without  this  danger. 

Besides  being  given  by  the  mouth,  mercury  may  be  also  em- 
ployed externally,  so  as  to  be  absorbed  by  the  skin,  and  this  method 
forms  a  useful  addition  to  the  other  modes  of  treatment.  In  cases 
where  the  internal  use  of  mercury  causes  great  disturbance,  very 
valuable  results  are  often  obtained  by  this  means,  which  allows  of 
the  treatment  Vjeing  continued  while  time  is  given  for  the  irritation 
of  the  alimentary  canal  to  subside.     Still,  as  Trousseau^  has  pointed 

'  Diday,  loc.  cit.  2  Clinique  Medicals. 


150  INHERITED    SYPHILIS. 

out,  mercurial  frictions  and  baths  do  not  always  act  as  safeguards 
against  gastro-intestinal  derangements.  The  frictions  are  made 
with  unguentum  hydrargyri,  half  a  drachm  of  which  is  rubbed 
into  the  sides  of  the  chest  once  a  day ;  or  a  flannel  band  smeared 
with  the  ointment  may  be  applied  round  the  chest  or  belly.  At 
the  same  time  great  cleanliness  must  be  observed :  each  morning 
the  surface  of  the  body  should  be  well  washed  with  soap  and  warm 
water,  so  that  all  the  old  ointment  may  be  removed  before  a  fresh 
application  is  made.  For  the  baths,  corrosive  sublimate  is  used, 
each  bath,  containing  half  a  drachm  of  the  salt.^  This  quantity 
may  be  gradually  increased  by  fifteen  grains  at  a  time,  to  a  drachm, 
or  a  drachm  and  a  half.  The  baths  should  be  used  every  two, 
three,  or  four  days,  unless  erythema  be  produced  by  their  employ- 
ment, when  the  quantity  of  the  sublimate  should  be  reduced,  or  the 
interval  between  successive  baths  should  be  increased.  Besides  the 
effect  npon  the  system  produced  by  the  absorption  of  the  mercu- 
rial salt,  the  baths  are  also  beneficial  by  their  local  action  upon  the 
cutaneous  lesions,  and  are  strongly  recommended  by  Trousseau  for 
this  purpose. 

Of  the  different  ways  of  treating  the  disease  thus  described,  we 
must  employ  one  or  another,  or  several  together,  according  to  the 
condition  of  the  infant.  The  more  intense  the  cachexia — i.e.,  the 
more  complete  the  hindrance  to  nutrition — the  more  important 
does  it  become  to  bring  the  system  as  quickly  as  possible  under 
the  influence  of  the  drug ;  but  unfortunately  it  is  in  these  cases 
that  the  susceptibility  of  the  stomach  and  bowels  to  the  irritating 
action  of  remedies  reaches  its  height.  Plere,  then,  the  external 
plan  of  treatment  becomes  of  such  extreme  importance,  and  it  must 
be  aided  by  the  cautious  administration  of  mercury  by  the  mouth, 
changing  from  one  preparation  to  another  as  circumstances  seem 
to  require  it. 

At  the  same  time,  every  effort  must  be  made  to  improve  general 
nutrition.  It  is  extremely  advisable  that  the  child  should  be 
suckled,  and  the  mother  is  of  course  the  person  upon  whom  that 
duty  would  naturally  fall.  Unfortunately,  however,  her  milk  is 
not  unfrcquently  so  altered  in  quality,  that  even  if  it  be  secreted 
in  sufficient  abundance,  which  is  far  from  being  always  the  case,  it 
is  \QYy  apt  to  be  difficult  of  digestion,  and  wanting  in   the  nutri- 

1  Diday,  loc.  cit. 


DIET. 


151 


tive  properties  so  necessary  for  the  efficient  nourishment  of  the 
infant. 

MM.  Vernois  and  BecquereV  from  an  analysis  of  nine  cases  of 
well-marked  constitutional  syphilis  in  the  mother,  not  under  treat- 
ment, give  the  following  results  of  their  researches  into  the  consti- 
tution of  the  milk  in  that  disease,  as  compared  with  the  milk  of  a 
healthy  woman : — 


Specific 
gravity. 

Water. 

Solid 
parts. 

Sugar. 

Ca.seia. 

Butter. 

Salts. 

Syphilis    .  .  . 

1034.05 

902.38 

97.62 

44.21 

35.26 

15.87 

2.28 

Health  .... 

1032.67 

889.08 

110.92 

43.64 

39.24 

26.66 

1.38 

It  will  thus  be  seen  that  the  density  of  the  milk  is  raised  without 
anj'  corresponding  increase  in  the  amount  of  the  solid  constituents, 
for  these,  on  the  contrary,  are  notably  diminished.  This  pecu- 
liarity may  be  partially  accounted  for  by  the  fall  in  the  quantity 
of  butter,  a  diminution  in  the  proportion  of  the  oily  constituent 
being  always  followed  by  a  rise  in  the  specific  gravity  of  the  fluid. 
The  increase  in  the  quantity  of  the  salts  may  also  aid  in  producing 
a  condition  which  is  not  found  in  any  other  chronic  disease.  The 
result,  however,  is  impoverished  milk  in  the  fullest  sense  of  the 
word,  for  while  the  water  which  it  contains  is  augmented,  the 
casein  and  the  butter,  elements  so  important  for  nutrition,  are 
diminished  in  quantity. 

Poor,  however,  as  is  the  quality  of  such  milk,  it  is  yet  better 
that  the  child  should  be  suckled  than  that  he  should  trust  entirely 
to  artificial  feeding  for  all  the  nourishment  he  requires.  Besides, 
the  analyses  just  quoted  were  all  made  upon  the  milk  of  women  in 
whom  the  syphilitic  symptoms  were  well  marked.  It  is  probable, 
therefore,  that  where  the  disease  assumes  a  milder  form,  the  devia- 
tions from  a  healthy  state  in  the  relative  proportions  of  the  several 
constituents  are  not  so  wide  as  in  the  cases  of  which  an  average  is 
given  above. 

If  the  secretion  of  milk  in  the  mother  be  scanty  (in  which  case 
it  is  almost  certainly  poor  and  watery),  or  if  it  appear  to  be  of  bad 
quality,  although  abundantly  secreted,  the  child  must  be  supplied 
with  some  other  food  in  addition  to  the  breast-milk.     This  is,  how- 


'  Du  Lait  chez  la  Femme,  par  MM.  Veruois  et  Becquerel.     8vo.    Paris,  1853. 


152  INHERITED    SYPHILIS. 

ever,  often  attended  by  considerable  risk.  It  must  be  remembered 
that  his  digestive  power  necessarily  shares  in  the  general  weakness 
of  the  whole  system,  and  that  food  which  a  healthy  child  could 
readily  digest  is  indigestible  to  him.  He  is  also  taking  medicines, 
the  common  tendency  of  which  is  to  produce  irritation  of  his 
alimentary  canal.  Now,  any  additional  irritation,  such  as  would 
be  produced  by  the  presence  of  undigested  food  would  necessarily 
cause  derangement  of  the  stomach  or  bowels,  or  both  ;  consequently 
the  administration  of  remedies  by  the  mouth  would  have  to  be 
suspended,  and  the  recovery  of  the  child  would  be  considerably 
retarded,  even  if  his  life  were  not  actually  exposed  to  danger. 

If  ass's  milk  can  be  obtained,  it  forms  the  most  suitable  addi- 
tion to  the  mother's  milk ;  if  not,  new  cow's  milk,  with  or  without 
lime-water  according  to  the  age  of  the  child,  must  be  resorted  to. 
This  should  be  given  from  a  feeding  bottle,  with  all  the  precau- 
tions recommended.  The  child  should  not  be  allowed  to  drink 
too  much  at  a  time,  the  quantity  given  and  the  frequency  of  its 
repetition  being  regulated  by  the  quantity  of  the  mother's  milk,  by 
the  age  of  the  infant,  and  by  the  readiness  with  which  the  meal  he 
has  previously  taken  seems  to  have  been  digested.  Farinaceous 
articles  of  diet  should  not  be  allowed  unless  the  child  be  at  least 
four  months  old. 

Cod-liver  oil  is  often  of  great  service  in  these  cases.  Five  or 
ten  drops  may  be  given  two  or  three  times  a  day,  in  a  spoonful  of 
the  milk  and  lime-water,  and  if  this  is  well  borne,  the  quantity 
may  be  gradually  increased  by  a  dropor  two  at  a  time.  If,  how- 
ever, it  causes  sickness  or  uneasiness,  it  must  be  stopped  at  once, 
to  be  recommenced  after  a  few  days,  and  in  smaller  doses.  If  any 
of  the  oil  appears  unchanged  in  the  stools  the  quantity  must  be 
reduced.  Should  the  skin  generally  be  healthy,  inunction  of  the 
oil  may  also  be  made  use  of,  a  teaspoonful  being  rubbed  into  the 
chest  once  or  twice  a  day.  If  the  skin  is  covered  by  the  syphilitic 
eruptions,  the  frictions  should  not  be  used  until  these  have  disap- 
peared. The  child  must  be  kept  in  an  equable  temperature  of 
from  60°  to  65°  Fahr.,  partly  in  order  to  avoid  the  risk  of  cold,  to 
which  he  is  particularly  susceptible  while  under  the  influence  of 
mercury;  partly,  on  account  of  the  beneficial  influence  upon  the 
disease  of  a  moderately  high  temperature,  for  all  writers  upon  this 
subject  unite  in  recommending  warmth  as  an  important  aid  to  the 
other  treatment. 


TREATMENT    OF    COMPLICATIONS.  153 

The  utmost  cleanliness  must  be  observed.  After  taking  food 
the  mouth  should  be  carefully  washed  out  with  a  piece  of  linen 
rag  dipped  in  warm  water,  to  prevent  any  accumulation  of  milk 
round  the  gums  and  cheeks — a  fruitful  source  of  thrush.  The 
napkins  must  be  changed  frequently,  and  the  buttocks  be  carefully 
sponged  and  dried  after  each  action  of  the  bowels,  for  all  unneces- 
sary irritation  of  the  skin  must  be  avoided,  and  the  continued 
contact  of  the  urine  and  stools  with  the  skin  promotes  the  occur- 
rence of  the  specific  erythema.  Besides,  cleanliness  is  important 
in  promoting  the  healing  of  mucous  patches  and  other  syphilitic 
sores  about  the  anus.  For  the  same  reason  the  whole  body  should 
be  bathed,  at  least  once  a  day,  with  warm  water,  care  being  taken 
to  dry  the  child  thoroughly  after  each  ablution. 

If  vomiting  occur,  the  internal  use  of  mercury  must  be  suspended, 
and  should  the  gastric  disturbance  still  continue,  the  child's  nour- 
ishment must  be  limited  to  his  mother's  milk.  If  the  vomiiing 
does  not  subside  by  this  means,  all  food  must  be  forbidden,  and 
the  child  be  allowed  nothing  but  cold  barley-water,  given  at  inter- 
vals with  a  teaspoon.  These  measures  usually  succeed  in  arrest- 
ing the  vomiting,  and,  in  most  cases,  the  mere  suspension  of  the 
mercury  is  suf&cient  to  produce  this  result.  Should  it,  however, 
continue,  a  hot  linseed-meal  poultice  must  be  applied  to  the  epigas- 
trium, and  a  powder  containing  one-sixth  of  a  grain  of  calomel, 
with  a  few  grains  of  powdered  chalk,  must  be  given  every  four 
hours  ;  or  a  mixture  containing  five  grains  of  bi-carbonate  of  soda 
to  a  teaspoonful  of  infusion  of  calumba  may  be  ordered  three 
times  a  day.  When  the  vomiting  is  obstinate  the  case  becomes 
one  of  great  danger. 

Diarrhoea  is  best  treated  by  suspending  the  mercurial,  and  if  this 
is  not  followed  by  stoppage  of  the  disorder,  a  mixture  of  chalk 
and  catechu,  with  aromatic  confection,  is  usually  sufficient  to  re- 
store the  bowels  to  their  natural  condition.  Diarrhoea  is  seldom 
obstinate  in  this  disease  if  the  directions  already  given  as  to  diet, 
and  avoidance  of  cold,  have  been  properly  attended  to. 

In  cases  where  either  of  these  symptoms  has  occurred,  great 
caution  is  necessary  in  returning  to  the  specific  treatment,  giving 
the  mercury  in  smaller  doses,  and  assisting  it  by  the  external  ap- 
plication of  that  drug,  either  in  the  form  of  baths  or  ointment. 

Local  applications  are  useful  as  aids  to  the  specific  treatment  in 
furthering  the  disappearance  of  the  local  lesions.     It  is  important 


154:  INHERITED    SYPHILIS. 

to  remove  these  local  symptoms  as  quickly  as  may  be,  for  although 
many  of  them  do  not  sensibly  affect  the  prognosis,  yet  others,  as 
the  condition  of  the  nose,  may  exercise  an  unfavorable  influence 
on  the  termination  of  the  disease.  Besides,  so  long  as  there  are 
contagious  sores  upon  the  body  of  the  child,  his  attendants  are 
liable  to  become  infected  by  direct  contagion,  and  this  danger 
should  be  removed  as  promptly  as  possible.  In  the  third  place,  a 
healthy  skin  is  indispensable  for  the  successful  employment  of  fric- 
tions, either  with  the  mercurial  ointment  or  with  cod-liver  oil. 

The  baths  of  corrosive  sublimate  have,  as  has  already  been 
stated,  a  very  favorable  influence  upon  the  cutaneous  lesions,  but 
there  are  other  special  applications  which  may  be  made  use  of  in 
treating  these  affections. 

When  the  nostrils  become  blocked  up  by  hard  crusts,  these  lat- 
ter should  be  gently  removed,  after  being  softened  by  warm  water 
and  cold  cream.  When  the  internal  surface  is  thus  laid  bare,  a 
little  mercurial  ointment  may  be  gently  applied  to  the  mucous 
membrane  lining  the  nostrils  with  a  feather,  or  with  a  piece  of  linen 
rag  rolled  up  into  the  form  of  a  slender  cylinder.  Diday  recom- 
mends for  this  purpose  an  ointment  composed  of  two  or  four  grains 
of  calomel  to  the  drachm  of  lard. 

Large  crusts  formed  on  the  body  should  be  removed  hy  covering 
them  with  a  thick  layer  of  lard,  and  laying  over  this  a  hot  bread- 
and-water  poultice.  This  should  be  applied  at  night,  and  in  the 
morning  the  softened  scab  can  be  easily  detached,  and  the  ulcer 
when  exposed  must  be  touched  with  the  solid  nitrate  of  silver. 

Mucous  patches  about  the  mouth  or  anus  must  be  well  touched 
with  the  same  caustic.  They  must  be  kept  very  clean,  as  previously 
directed.  Kicord  orders  the  patches  to  be  washed  twice  a  day  with 
a  solution  of  chloride  of  soda,  and  after  each  washing  a  small 
quantity  of  calomel  is  to  be  applied  with  pressure.  Diday  speaks 
very  highly  of  this  way  of  treating  them. 

Mercurial  treatment  must  be  continued  sufficiently  long  to  enable 
us  to  hope  that  the  disease  is  not  only  arrested  but  cured.  The 
disappearance  of  the  eruption  is  not  enough  to  give  us  this  assur- 
ance, so  long  as  the  child  remains  weak  and  emaciated.  Even 
after  all  the  symptoms  have  disappeared,  it  is  advisable  to  continue 
the  treatment  for  some  time  longer,  being  guided  by  the  condition 
of  the  patient  and  by  the  severity  of  the  symptoms  by  which  the 
disease  manifested  itself.      Diday  recommends  that,  as  a  rule,  spe- 


EELAPSES.  155 

cific  treatment  should  be  continued  for  three  months,  dating  from 
its  first  commencement,  provided  that  mercury  has  been  adminis- 
tered directly  to  the  child, 

Eelapses  are,  however,  very  liable  to  occur;  and  it  must  be 
remembered  that  these  are  frequently  determined  by  some  illness, 
as  any  of  the  minor  disorders  peculiar  to  childhood;  by  any- 
thing, in  fact,  which,  temporarily  lowering  the  child's  strength  and 
suspending  healthy  nutrition,  allows  the  poison,  subdued  but  not 
destroyed,  to  resume  something  of  its  former  ascendency. 

When  specific  treatment  is  abandoned  it  is  generally  advisable 
to  give  a  tonic  as  a  mineral  acid  with  bitter  infusion,  quinine,  iron, 
cod-liver  oil,  &c. 

Dr.  West  especially  recommends  the  syrup  of  the  iodide  of  iron 
as  being  very  valuable  in  these  cases. 


CHAPTER   VI. 

MUCOUS   DISEASE. 

Mucous  Disease. — Character  of  tlie  derangements. 

Sj/mptoms. — Loss  of  flesh,  color,  and  spirits — Restlessness  at  night — Somnambulism 
— Nocturnal  incontinence  of  urine — Apjjearance  of  tongue — Bowels — Com- 
plexion— Skin — Lymphatic  glands — Progression  of  symptoms — Bilious  attacks 
— Worms  a  common  complication. 

Causes. — Previous  diseases,  especially  whooping-cough — Second  dentition. 

Diagnosis. — Resemblance  to  chronic  tuberculosis — Points  of  distinction — Tempe- 
rature. 

Treatment. — Diet — Farinaceous  food  bad — Dietary — Attention  to  skin — Warm 
clothing — Drugs — Alkalies  to  be  preferred  to  acids — Aloes — Iron — Illustrative 
case — A  change  sometimes  advisable  to  acid  medicines — Alum — Bracing  air. 

Mucous  disease,  a  very  frequent  disorder  amongst  children,  may 
be  met  with  at  any  age,  but  is  most  common  between  three  or  four 
and  ten  or  twelve  years.  The  derangement  consists  in  an  in- 
creased secretion  of  mucus  from  the  whole  internal  surface  of  the 
alimentary  canal :  it  is  a  mucous  flux  which  interferes  mechani- 
cally with  digestion  and  absorption  of  the  food,  and  by  its  influence 
in  impeding  general  nutrition  often  excites  suspicions  of  the 
existence  of  tubercle. 

Syynpioms. — These  vary  in  intensity  according  to  the  degree  to 
■which  nutrition  is  interfered  with.  At  first  they  are  usually  slight, 
but  become  more  severe  as  the  derangement  becomes  more  marked. 
Thus,  the  child  gets  languid  and  dull;  he  is  disinclined  to  exer- 
tion, and  complains  of  weariness  and  depression.  He  grows  pale 
and  loses  flesh  ;  his  spirits  are  low ;  he  ceases  to  takes  interest  in 
his  accustomed  amusements,  and  sits  listless  and  moody,  sometimes 
crying  without  apparent  cause.  He  is  often  drowsy  in  the  day  but 
is  restless  at  night,  grinding  his  teeth ;  and  his  sleep  is  often  dis- 
turbed by  frightful  dreams,  from  which  he  wakes  in  great  terror, 
crying  and  talking  incoherently.  The  conduct  of  the  child  at 
night  is  often  extremely  perplexing  to  his  relatives.     Sometimes 


SYMPTOMS.  157 

lie  will  start  from  his  sleep  with  a  loud  cry,  and  will  remain  for  a 
considerable  time  under  the  influence  of  the  most  violent  panic, 
uttering  wild  exclamations,  and  being  apparently  unable  to  recog- 
nize the  familiar  faces  of  those  who  are  endeavoring  to  soothe  him. 
At  other  times  he  will  rise  from  his  bed  still  asleep,  and  will  walk 
from  room  to  room.  In  fact,  most  of  the  cases  of  somnambulism 
in  children  are  due  to  this  cause.  Nocturnal  incontinence  of  urine 
is  also  not  unfrequently  complained  of,  and  this,  although  in  the 
beginning  only  occasional,  may  afterwards  become  habitual. 

The  appetite,  at  first  unusually  keen,  becomes  gradually  capri- 
cious, then  fails  almost  entirely,  and  each  meal  is  followed  after 
some  little  interval  by  flatulence  and  uneasiness.  The  appetite 
may,  however,  remain  large  even  after  the  emaciation  has  become 
extreme,  and  in  some  cases  the  hunger  seems  almost  insatiable, 
the  child  very  shortly  after  a  full  meal  asking  again  for  food. 

The  tongue  is  generally  flabby  and  indented  at  the  edges  by  the 
teeth,  but  it  has  besides  a  peculiar  appearance,  which  is  very 
characteristic.  This  appearance  is  due  to  the  mucus  with  which  it 
is  covered,  for  the  glands  of  the  mouth  are  as  active  in  their  secre- 
tion as  those  of  the  other  parts  of  the  alimentary  canal.  A  glossy, 
slimy  look  is  thus  given  to  the  organ,  which  is  quite  distinct  from 
the  moist  appearance  produced  by  saliva  alone,  and  resembles 
more  the  aspect  it  would  bear  if  brushed  over  with  a  solution  of 
gum.  This  slimy  look  is  not  always  general,  but  in  slightly 
marked  cases  is  limited  to  a  spot  in  the  centre  of  the  dorsum,  the 
rest  of  the  surface  and  the  sides  having  the  ordinary  aspect.  The 
tongue  is  either  perfectly  clean  or  is  covered  with  a  thin  gray- 
coating  of  fur.  The  fungiform  papillge  at  the  sides  of  the  dorsum 
are  also  unusually  distinct.  They  are  seen  as  large  round  or  oval 
spots,  seldom  elevated,  and  varying  in  color  from  pale  red  to  deep 
crimson ;  the  depth  of  color  being  in  proportion  to  the  degree  of 
irritability  of  the  digestive  organs.  If  vomiting  or  diarrhoea 
supervene  their  color  becomes  bright  red,  and  they  then  project 
slightly  above  the  surface,  peering  through  the  thick  coatincr  of 
yellow  fur  with  which  the  dorsum  in  such  cases  is  usually  covered. 
Sometimes  a  different  appearance  is  presented,  and  the  whole 
tongue  is  clean  with  a  glazed  glossy  look  as  if  entirely  denuded 
of  epithelium. 

The  bowels  are  either  constipated,  or  there  are  frequent  scanty 
stools  containing  large  quantities  of  free  mucus;    and  the  evacua- 


158  MUCOUS    DISEASE. 

tions  are  generally  accompanied  by  much  straining,  and  sometimes 
by  prolapse  of  the  bowel.  It  is  not  uncommon  to  find  constipation 
and  diarrhosa  alternating  with  one  another.  Thus,  the  bowels  are 
confined  for  two  or  three  days  or  even  for  a  whole  week  ;  a  violent 
attack  of  purging  then  sets  in,  the  bowels  being  opened  ten,  twelve, 
or  even  more  times  in  the  twenty -four  hours ;  after  which,  the 
accumulation  having  been  discharged,  the  bowels  become  again 
confined.  Sometimes  the  breath  is  extremely  offensive,  especially 
in  the  mornings,  and  this  is  often  dependent  upon  enlarged  tonsils, 
which  secrete  a  thick  bad-smelling  semi-purulent  matter.  The 
fetor  of  the  breath  may,  however,  be  present  although  the  tonsils 
are  quite  healthy.  In  these  cases  glands  at  the  back  of  the  pharynx 
will  be  usually  found  loaded  with  an  offensive  yellow  secretion. 

The  complexion  is  often  remarkably  sallow,  having  a  half-jaun- 
diced tint;  and  this  varies  in  degree  from  day  to  day,  the  color 
being  most  dingy  at  the  time  when  the  nervous  symptoms  are 
most  strongly  marked.  At  these  times,  too,  the  child  is  apt  to 
complain  of  headache,  or  of  wandering  pains  about  the  chest  or 
belly. 

.  The  skin  ceases  to  act  at  a  very  early  stage  of  the  disease,  and 
soon  becomes  rough  and  harsh,  especially  about  the  chest,  arms, 
and  belly.  In  extreme  cases  the  whole  body  is  covered  with  little 
scales  of  epithelium,  which  can  be  rubbed  off  as  a  fine  dust. 

The  lymphatic  glands  of  the  neck  are  liable  to  become  enlarged 
on  the  slightest  irritation.  They  do  not,  however,  necessarily  sup- 
purate or  remain  permanently  swollen.  The  enlargement,  after 
persisting  for  a  variable  time,  may  disappear  completel3^ 

The  temperature  of  the  body  is  seldom  elevated  above  the  nor- 
mal level. 

The  symptoms  thus  described  do  not  progress  in  any  regular 
manner  from  bad  to  worse.  It  is  usually  found  that  the  child  is 
subject  every  few  weeks  to  what  are  called  "  bilious  attacks" — 
to  violent  attacks,  that  is,  of  vomiting  and  purging,  lasting  often 
for  several  days,  during  which  large  quantities  of  mucus  are  got 
rid  of  The  system  being  thus  relieved,  the  symptoms  become  for 
a  tinie  less  severe  ;  the  child  sleeps  better  at  night,  and  during  the 
day  is  less  languid,  and  more  inclined  to  take  exercise.  The  im- 
provement is  not,  however,  of  long  continuance;  for  the  symptoms 
returning,  grow  gradually  worse  until  they  culminate  in  another 
violent  attack  like  the  former.     In*  this  way  the  child  may  go  on 


WORMS    A    COMMON    COMPLICATION.  159 

for  months,  getting  gradually  thinner  and  weaker,  his  condition 
exciting  the  gravest  apprehensions  amongst  his  relatives,  especially 
as  a  short  hacking  cough  is  a  not  unfrequent  symptom  of  this 
derangement,  and  increases  their  fears  of  the  outset  of  consump- 
tion. Examination  of  the  lungs,  however,  in  an  uncomplicated 
case  of  raucous  disease  will  reveal  no  signs  of  pulmonary  mischief. 
Worms,  especially  amongst  the  poorer  classes,  form  a  common 
complication  of  this  derangement ;  in  which  case  the  symptoms  are 
all  attributed  to  the  presence  of  the  entozoa.  The  creatures  find 
in  the  alkaline  mucus  a  congenial  nidus ;  but  the  disordered  state 
of  the  mucous  membrane  is  at  least  as  important  as  are  the  para- 
sites themselves,  and  until  the  alimentary  canal  is  restored  to  a 
more  healthy  condition,  special  anthelmintics  frequently  fail  of 
success.  The  difficulty  so  often  experienced  in  curing  a  child  of 
worms  is  due  to  neglect  of  the  measures  necessary  effectually  to 
restrain  this  unnatural  activity  of  the  mucous  glands.  The  sub- 
ject of  worms  will,  however,  be  more  conveniently  treated  of  in 
another  chapter. 

It  is  easy  to  understand  how  nutrition  must  suffer  in  this  dis- 
ease. The  mucus  poured  out  into  the  stomach  and  bowels  seems, 
to  act  as  a  ferment,  and  to  cause  decomposition  of  the  food  with 
which  it  comes  into  contact.  At  the  same  time  the  alimentary 
masses,  being  enveloped  by  a  coating  of  thick  slimy  matter,  are 
prevented  from  being  properly  mixed  up  with  the  digestive  fluids, 
a  comparatively  small  part  of  the  food  which  has  been  taken  is 
therefore  converted  into  a  form  in  which  it  is  capable  of  being  ab- 
sorbed ;  and  of  that  small  part  a  still  smaller  is  actually  taken  up 
by  the  absorbent  vessels,  on  account  of  the  thick  layer  of  viscid 
mucus  which  lines  the  walls  of  the  bowel,  and  prevents  the  veins 
and  the  lacteals  from  performing  their  functions.  The  acid  resulting 
from  the  fermentation  of  starchy  food  increases  the  consistence  of 
the  mucus  by  partially  coagulating  it ;  and  the  irritating  action  of 
the  sour  contents  of  the  bowel  upon  the  lining  membrane  excites 
further  secretion  from  the  glands. 

The  large  appetite  so  commonly  found  in  these  cases  is,  no  doubt, 
in  part,  a  manifestation  of  the  want  of  nourishment  felt  through- 
out the  system ;  but  it  is  probably  also,  in  part,  a  morbid  craving 
excited  by  the  stimulating  action  of  the  fermenting  contents  of  the 
stomach  and  bowels. 

Causes. — In   children  there  is  naturally  great  activity  of  the 


160  MUCOUS    DISEASE. 

mucous  membrane  lining  tlie  alimentary  canal.  As  compared  with 
the  adult  its  secretion  appears  in  them  to  be  always  in  excess,  and 
a  very  slight  irritation  is  sufficient  to  increase  it.  The  stools  of 
young  infants  are  in  their  natural  state  composed  in  great  part  of 
mucus,  and  any  passing  irritation,  such  as  a  meal  of  indigestible 
food,  or  a  slight  chill,  causes  at  once  a  great  augmentation  of  the 
secretion ;  the  so-called  slimy  stools  are  then  passed,  consisting  of 
thick  viscid  mucus,  mixed  up  more  or  less  intimately  with  the 
fecal  matter.  In  cases  where  the  irritation  is  constantly  renewed, 
as  occurs  in  children  who  are  habitually  fed  upon  indigestible 
food,  large  quantities  of  mucus  are  passed,  often  coating  the  small 
fecal  masses,  or  appearing  separately  as  strings  and  jelly-like 
lumps. 

Certain  diseases  are  apt  to  leave  behind  them  this  condition  of 
the  bowels :  thus,  measles  and  scarlatina  may  be  sometimes  followed 
by  it.  Whooping-cough  is,  however,  of  all  diseases  the  one  to  which 
this  derangement  can  most  commonly  be  traced,  and  there  is  a  spe- 
cial reason  why  this  should  be  so.  In  whooping-cough  the  bronchial 
mucous  membrane  secretes  a  tough  stringy  mucus  in  very  large  quan- 
tities, and  there  is  at  the  same  time  a  copious  mucous  flux  from  the 
stomach  and  bowels.  The  abundant  thick  mucus  which  is  vomited 
at  the  termination  of  the  characteristic  cough  comes  in  great  part 
from  the  stomach,  and  the  involuntary  evacuations  which  are  so  fre- 
quently found  to  follow  a  paroxysm,  contain  much  of  the  same  se- 
cretion. The  tongue  in  all  severe  cases  of  whooping-cough  will  be 
found  to  correspond  exactly  with  the  appearance  of  the  organ  de- 
scribed as  characteristic  of  mucous  disease;  in  fact,  an  acute  attack 
of  this  intestinal  derangement  is  a  constant  accompaniment  of  severe 
pertussis.  As  the  whooping-cough  lessens  in  severity,  the  derange- 
ment of  the  alimentary  canal  frequently  subsides ;  but  in  many  cases, 
especially  if  the  child  be  weakly,  or  be  much  reduced  by  the  inten- 
sity or  the  long  continuance  of  the  disease,  the  flux  from  the  bowels 
continues  and  becomes  a  chronic  condition.  It  is  for  this  reason 
that  whooping-cough  is  so  much  to  be  dreaded  in  weakly  children. 
The  disease  not  only  interferes  with  nutrition  while  actually  in  pro- 
gress, but  also  leaves  behind  it  a  chronic  derangement  of  the  bowels 
which  often  produces  extreme  emaciation,  and  may  favor  the  oc- 
currence of  very  serious  diseases. 

The  existence  of  mucous  disease  as  a  sequel  of  whooping-cough 
seems  also  to  favor  the  recurrence  of  the  characteristic  cough  alter 


DIAGNOSIS.  161 

apparent  recovery  from  pertussis,  and  long  after  all  chest  symptoms 
have  subsided.  The  child  is  exposed  to  cold,  begins  to  cough,  and 
the  cough  assumes  the  convulsive  character  rendered  so  familiar  by 
his  previous  attack.  Most  cases  of  true  relapsed  whooping-cough 
occur  in  patients  in  whom  the  stomach  and  bowels  have  been  left 
in  the  condition  described.  It  may,  however,  be  noticed  that  many 
eases  of  so-called  relapsed  pertussis  are  not  cases  of  real  relapse ; 
are  not,  that  is  to  say,  cases  of  recurrence  of  the  disease  after  com- 
plete subsidence  of  all  pulmonary  symptoms.  It  is  not  uncom- 
mon for  the  whoop  which  had  become  faint  and  rare,  so  as  to  be 
scarcely  remarked,  to  return  with  its  former  frequency  and  vigor 
under  the  influence  of  a  fresh  catarrh. 

The  commencement  of  the  second  dentition  is  also  a  time  at 
which  this  derangement  is  not  unfrequently  set  up.  Children  are 
often  found  as  the  early  teeth  begin  to  be  displaced  by  the  second 
crop  to  grow  pale,  and  thin,  and  languid ;  indeed,  so  frequently  is 
this  found  to  occur  that  the  commencement  of  the  second  dentition 
is  looked  upon  as  one  of  the  critical  periods  of  early  life.  There 
is  no  doubt  that  owing  to  the  intimate  sympathy  existing  between 
all  parts  of  the  alimentary  canal,  there  is  at  the  time  of  dentition  a 
great  tendency  to  increased  activity  of  secreting  function  and  an 
increased  susceptibility  to  disturbing  influences. 

Diagnosis. — The  symptoms  of  this  derangement  present  a  re- 
markable resemblance  to  those  of  chronic  tuberculosis  with  which 
it  is  so  often  confounded ;  the  distinguishing  points  between  the 
two  diseases  are  therefore  of  much  importance. 

The  most  characteristic  symptoms  of  mucous  disease  are :  the 
slimy  appearance  of  the  tongue  ;  the  large  quantities  of  free  mucus 
in  the  stools  ;  the  great  want  of  regularity  in  the  progression  of 
the  symptoms ;  and  the  periodical  occurrence  of  bilious  attacks. 
If  these  conditions  are  observed  to  follow  an  attack  of  whooping- 
cough,  or  to  occur  at  the  time  of  the  second  dentition,  if  they  are 
accompanied  by  dry  rough  skin  and  sallow  complexion,  and  if  the 
temperature  of  the  body  is  not  raised  above  the  natural  level,  we 
may  conclude  that  the  illness  is  due  to  the  cause  which  has  been 
described. 

With  regard  to  the  heat  of  the  body  it  must  be  remembered 
that  a  continued  elevation  of  temperature  is  necessary  to  demon- 
strate the  existence  of  tuberculosis.     In  mucous  disease  the  tem- 
perature  may   be   elevated  temporarily   by   passing    sources  of 
11 


162  MUCOUS    DISEASE. 

irritation,  and  thus  may  be  found  to  be  high  on  two  or  three 
successive  days.  In  these  cases,  therefore,  some  caution  should  be 
exercised  in  making  a  diagnosis,  and  further  observations  will  be 
necessary  before  we  can  feel  ourselves  justified  in  giving  a  posi- 
tive opinion  upon  the  nature  of  the  disease. 

Cases,  however,  of  this  derangement  occur  in  which  the  tempe- 
rature rises  and  remains  elevated,  perhaps  permanently,  although 
the  symptoms  in  other  respects  correspond  to  those  of  mucous 
disease.  Pneumonia  is  very  apt  to  attack  such  patients,  and  it  is 
not  at  all  uncommon  for  the  deposit,  remaining  entirely  or  par- 
tially unabsorbed,  to  undergo  cheesy  transformation  and  form  the 
so-called  scrofulous  pneumonia ;  one  of  the  many  varieties  of  pul- 
monary phthisis.  In  such  cases  it  is  often  a  very  nice  point  to 
decide  upon  the  presence  or  absence  of  gray  tubercle,  but  by 
careful  consideration  of  the  history  of  the  acute  attack,  and  by 
minute  observation  of  the  seat  and  progress  of  the  physical  signs, 
a  diagnosis  can  be  generally  arrived  at  (see  diagnosis  of  pulmonary 
phthisis).  If  the  formation  of  gray  tubercle  occur  at  all  in  such 
cases,  the  coincidence  must  be  looked  upon  as  accidental,  for 
mucous  disease  is  quite  distinct  from  the  tuberculous  diathesis 
and  independent  of  it. 

Treatment. — For  the  cure  of  this  derangement  the  strictest  at- 
tention to  diet  is  indispensable.  The  morbid  condition  to  be  over- 
come is  the  excessive  secretion  of  mucus  from  the  whole  lining 
of  the  alimentary  canal,  and  one  of  the  most  effectual  measures  for 
restraining  this  morbid  glandular  activity  is  the  prohibition  of  all 
articles  of  diet  capable  of  undergoing  fermentation,  and  so  of  in- 
creasing the  irritation  of  the  mucous  membrane.  All  farinaceous 
articles  of  diet,  except  bread,  must  be,  therefore,  at  once  forbidden, 
and  even  the  bread  must  be  considerably  restricted  in  quantity, 
and  should  be  eaten  stale,  or  in  the  form  of  dry  toast.  Potatoes,  peas, 
beans,  turnips,  carrots,  parsnips,  fruit,  cakes,  pastry,  and  butter  must 
all  be  excluded  from  the  diet,  and  the  child  should  be  nourished  as 
nearly  as  possible  upon  meat,  eggs,  and  milk.  Too  much  food  is 
not  to  be  given  at  once,  for  all  overloading  of  the  stomach  is  to  be 
avoided.  It  is  better  to  distribute  the  amount  allowed  over  four 
meals  rather  than  three,  and  these  should  be  fixed  at  regular  in- 
tervals throughout  the  day. 

A  good  scale  of  diet  for  a  child  over  two  years  old  is  the  follow- 
ing, given  as  four  separate  meals  in  the  course  of  the  day  : — 


DIET.  163 

First  meal. — Fresh  milk,  diluted  with  a  third  part  of  lime-water, 
or  alkalinized  with  from  ten  to  twenty  drops  of  the  saccharated 
solution  of  lime.     A  small  slice  of  dry  toast  or  of  dry  stale  bread. 

Second  meal. — A  small  mutton  chop,  or  a  slice  of  roast  mutton 
or  beef  without  fat.  Dry  toast  or  stcile  bread.  If  the  child  be  four 
or  five  years  old  he  may  take  with  this  meal  a  little  vegetable  as 
well-boiled  cabbage,  spinach,  or  broccoli, 

Tiiird  meal. — A  cup  of  beef-tea  or  mutton-broth,  free  from 
grease;  or  the  yelk  of  a  lightly -boiled  egg]  dry  toast. 

Fourth  meal. — The  same  as  the  first. 

It  is  not  always  easy  to  persuade  children  to  submit  readily  to 
the  deprivation  of  starchy  food,  for  whicb,  and  especially  for  pota- 
toes, there  is  often  in  these  cases  a  great  craving.  So  long,  how- 
ever, as  the  slimy  appearance  of  the  tongue,  before  described, 
continues  to  be  observed,  the  above  diet  should  if  possible  be 
adhered  to.  AVhen  potatoes  are  once  more  allowed  they  must  be 
well-boiled,  and  should  be  afterwards  carefully  mashed  with  a 
spoon.  Gravy  may  be  poured  over  them  before  they  are  eaten. 
A  good  substitute  for  potatoes  in  these  cases  is  the  flower  of  cauli- 
flower very  well  boiled.  Other  allowable  vegetables  are  spinach, 
turnip-greens,  asparagus,  French  beans,  lettuce  and  celery  (stewed). 
The  diet  may  be  varied  by  substituting  for  the  mutton-chop  a  little 
roast  chicken  or  game.  Well-boiled  turbot,  cod,  sole,  or  mackerel 
may  also  be  permitted.^ 

Alcohol  may  be  given  with  advantage  in  many  of  these  cases, 
and  where  the  strength  has  been  much  reduced  is  of  considerable 
service  in  improving  the  appetite  and  increasing  the  digestive 
power.  Half-a-glass  of  dry  sherry  diluted  with  water  may  be 
taken  at  dinner,  or  double  the  quantity  of  light  claret  and  water. 
Light  bitter  ale  is  also  permissible,  if  the  child  will  take  it. 

When  the  derangement  has  existed  for  some  time,  and  the 
general  nutrition  of  the  body  is  much  lowered,  the  appetite  may 
fail.  In  these  cases,  it  is  often  difficult  to  persuade  the  child  to 
take  nourishment,  especially  as  his  chief  craving  is  for  bread  and 
butter,  potatoes,  and  all  the  different  articles  of  diet  which  are 
particularly  injurious.  Meat  is  in  these  cases  often  extremely 
distasteful  to  him.  A  lark  or  a  snipe  will,  however,  by  appealing  to 
his  fancy,  sometimes  overcome  this  dislike,  and  every  means  should 

'  For  tabulated  diets,  see  Chapter  XI,  Diets  19,  20,  21. 


164  MUCOUS    DISEASE. 

be  tried  by  varying  his  diet  within  the  prescribed  limits  to  induce 
him  to  take  a  sufficient  quantity  of  food. 

At  the  same  time  every  effort  should  be  made  to  restore  the 
proper  action  of  the  skin.  At  night  the  child  must  be  bathed 
with  hot  water,  and  after  being  carefully  dried  must  be  anointed 
over  the  whole  body  with  warm  olive  oil :  this  process  to  be  re- 
peated regularly  every  evening  at  bedtime.  In  cases  where  the 
skin  is  especially  dry  and  rough,  it  is  well  on  the  first  evening  to 
remove  the  hardened  epithelium  by  a  thorough  scrubbing  with 
soap,  using  hot  water  softened  by  the  addition  of  a  handful  of 
carbonate  of  soda.  Every  morning  the  child  should  be  sponged 
in  a  bath  with  water  of  the  temperature  of  60°  Fah.,  and  should 
be  afterwards  rubbed  with  towels  or  a  flesh  glove  until  the  skin 
is  all  aglow.  Under  such  treatment  the  skin  will  quickly  recover 
its  natural  appearance  and  become  soft  and  supple. 

The  child  should  be  warmly  clothed,  and  should  take  plenty  of 
exercise  in  the  open  air :  if  the  weather  be  mild,  almost  the  whole 
day  should  be  passed  out  of  doors.  He  should  wear  a  shirt  and 
drawers  of  flannel,  and  his  belly  should  have  the  additional  pro- 
tection of  a  broad  flannel  belt. 

The  above  measures — even  if  no  medicines  have  been  given  at 
all — will  after  a  very  short  time  produce  a  marked  improvement 
in  the  appearance  of  the  child.  The  stoppage  of  starchy  food,  and 
especially  of  potatoes,  will  by  itself  remove  a  great  many  of  the 
more  distressing  symptoms ;  the  restlessness  at  night  in  particular, 
usually  ceases  at  once.  There  are,  however,  certain  medicines 
which  should  not  be  neglected  ;  but  those  most  calculated  to  assist 
the  object  we  have  in  view,  are  not  those  which  under  the  name 
of  tonics  are  usually  resorted  to  when  from  any  cause  healthy 
nutrition  of  the  body  appears  to  be  in  abeyance.  The  best  tonic 
is  nourishing  food.  But  that  the  food  taken  may  be  nourishing, 
it  must  first  of  all  be  digested ;  and  those  medicines  will  be  the 
real  tonics  which  enable  the  alimentary  canal  properly  to  perform 
its  functions.  Our  object,  as  has  been  before  remarked,  is  to 
check  as  rapidly  as  possible  the  excessive  secretion  of  mucus 
which  prevents  the  food  from  being  sufficiently  mixed  with  the 
digestive  fluids,  and  impedes  the  action  of  the  absorbent  vessels. 
Various  medicines  will  accomplish  this  result.  Thus,  alkalies  not 
only  appear  to  have  an  influence  in  arresting  the  secretion  of 
mucus,  but  also,  by  at  once  neutralizing  any  acid  formed   by  the 


VALUE    OF    ALKALIES.  165 

fermentation  of  food,  produce  a  rapid  change  for  the  better  in  the 
general  symptoms.  The  best  form  in  which  they  can  be  given  is 
the  bicarbonate  of  soda  with  a  bitter,  as  the  infusion  of  calumba. 
To  each  dose  may  be  added  half  a  grain  of  iodide  of  potassium,  to 
increase  the  salivary  secretion,  and  twenty  drops  of  the  tincture  of 
myrrh,  which  is  found  to  have  a  powerful  bracing  effect  upon  the 
mucus  membrane.  The  mineral  acids — at  any  rate  in  severe  cases 
of  this  derangement — often  appear  to  be  rather  injurious  than 
beneficial;  certainly  the  improvement  under  their  use  is  not  nearly 
so  rapid  as  in  cases  where  alkalies  are  used.  The  influence  of  the 
latter  in  improving  the  appetite,  when  that  is  failing,  is  most 
marked,  especially  if  a  drop  or  two  of  dilute  hydrocyanic  acid  be 
added  to  each  dose  of  the  mixture,  and  will  often  succeed  when 
dilute  nitric  acid  has  been  given  without  any  effect. 

Aloes  is  also  a  most  valuable  medicine.  Under  its  use  the 
amount  of  mucus  appearing  in  the  stools  diminishes  rapidly,  the 
digestion  improves,  and  all  the  symptoms  showing  irritability  of 
the  nervous  system — such  as  restlessness  at  night,  bad  dreams, 
startings,  grinding  of  the  teeth,  moroseness,  and  ill  temper — quickly 
subside.  The  effect  upon  the  rest  at  night  is  usually  most  marked, 
the  child  beginning  to  sleep  soundly  after  only  a  few  doses  of  the 
drug.  The  most  convenient  form  in  which  it  can  be  given  is  the 
compound  decoction,  which  if  well  made  is  seldom  objected  to  by 
children ;  the  liquorice  and  the  compound  tincture  of  cardamoms 
it  contains  very  effectually  disguising  the  nauseous  bitter  of  the 
aloes.  It  may  be  given  in  doses  of  one  or  two  drachms  twice  or 
three  times  in  the  day.  In  such  quantities,  especially  if  taken 
between  the  meals,  it  does  not  act  as  a  purgative,  but  merely  pro- 
duces a  tonic  effect  upon  the  bowels,  checking  immoderate  secretion. 

It  must  be  stated,  however,  that  the  aloes  appears  to  be  more 
beneficial  in  winter  than  in  summer.  In  warm  weather  it  is  apt 
to  be  too  irritating,  exciting  looseness  of  the  bowels.  When  such 
is  the  case,  the  drug  should  be  at  once  stopped,  and  a  change  be 
made  to  alkalies,  or  to  some  of  the  other  preparations  recom- 
mended. 

Decoction  of  oak  bark  in  half-ounce  doses  is  also  often  of 
service. 

In  cases  where  the  emaciation  and  debility  are  very  decided, 
iron  may  be  combined  with  the  special  treatment ;  for  although 
tonics,  when  given  alone,  are  found  to  be  of  slight  advantage  so 


166  MUCOUS    DISEASE. 

long  as  the  functional  derangement  of  the  alimentary  canal  con- 
tinues marked,  yet  in  combination  with  remedies  directed  espe- 
cially to  rectify  that  derangement,  iron  is  often  of  much  use. 
Thus,  the  citrate  of  iron  and  ammonia  may  be  given  with  sal  vola- 
tile in  the  alkaline  mixture,  or  a  teaspoonful  of  iron  wine  may  be 
added  to  each  dose  of  the  decoction  of  aloes,  or  the  aloes  may  be 
combined  with  the  tartrate  of  iron  and  potash,  as  in  the  following 
mixture  : — 

;^.   Ferri  et  potas.  tartratis,  3iss  ; 
Decocti  aloes  co.,  §ij  ; 
Aq.  ad  5vj.     M.     333  ter  die. 

While  these  medicines  are  being  taken,  a  purgative  of  rhubarb 
and  jalap  should  be  given  fasting  twice  a  week  to  clear  away  any 
excess  of  mucus  from  the  bowels ;  and  if,  as  is  so  often  the  case 
worms  be  present,  special  measures  for  their  expulsion  must  be 
resorted  to,  as  will  be  described  in  the  following  chapter. 

The  following  case  well  illustrates  the  rapid  improvement  which 
takes  place  when  the  above  treatment  is  adopted. 

"John  E.,  aged  11  years.  Had  scarlatina  three  years  ago,  and 
has  since  been  persistently  wasting. 

He  was  first  seen  on  February  25.  A  very  pale,  thin  boy,  sub- 
ject to  occasional  attacks  of  faintness,  without  however  actually 
losing  consciousness.  Face  has  a  care-worn  look,  and  he  is  troubled 
with  an  occasional  short  hacking  cough.  Appetite  very  bad. 
Tongue  thickly  furred  and  slimy  looking,  with  depressed  large 
pink  papillae  covering  its  dorsum  and  sides.  Bowels  confined, 
acting  about  every  other  day :  stools  hard  and  dark,  the  fecal  mat- 
ter often  covered  with  mucus.  Occasionally  threadworms  are 
seen  in  the  motions.  Sleeps  very  badly,  and  often  seems  to  be 
'light-headed'  at  night.  Is  not  subject  to  attacks  of  purging. 
Never  perspires :  the  skin  all  over  body  is  exceedingly  rough  and 
harsh  ;  chest  and  belly  covered  with  coarse,  dry  epithelium,  which 
can  be  rubbed  off  as  a  fine  dust.  Examination  of  the  lungs  and 
heart  shows  no  signs  of  disease  in  those  organs. 

The  boy  was  ordered  to  be  well  scrubbed  at  bedtime  with  soap 
and  hot  water  containing  soda:  after  which  the  whole  body  to  be 
smeared  over  with  warm  olive  oil.  The  oiling  to  be  repeated 
every  night  after  bathing  with  hot  water.  In  the  morning  to  have 
a  sponge  bath  of  the  temperature  of  60°  Fahr. 


CASE    ILLUSTRATING    TREATMENT.  167 

Diet  to  consist  of  meat,  eggs,  and  milk,  with  a  little  dry  stale 
bread. 

The  foUowinor  medicines  were  ordered : — 

o 

^.  Pulv.  rlisei, 

Pulv.  jalapse,  aa  gr.  vij ; 

Pulv.  scarainon.,  gr.  x.     Ft.  pulv.  iv. 
j  alternS,  mane  sumend. 
J^.  Deoocti  aloes  co., 

Vini  ferri,  aa  3iij.     M.     §ss  ter  die. 

The  improvement  in  this  case  was  most  rapid.  In  a  week's 
time  the  skin  had  become  naturally  soft  and  supple,  and  the  boy 
was  beginning  to  gain  flesh.  His  appetite  improved,  and  he  slept 
better  at  night.  The  increase  in  weight  was  very  remarkable. 
He  weighed  on  March  8,  fifty-seven  pounds ;  on  March  6,  fifty- 
eight  pounds ;  and  on  March  15,  sixty-two  pounds.  By  this  date 
(March  15)  the  boy's  appearance  was  quite  changed ;  he  had  com- 
pletely lost  the  care-worn  look  which  had  been  so  noticeable  on 
his  face  at  the  first  visit,  and  the  cheeks  were  much  fuller,  although 
still  p^le.  The  body  generally  was  much  fatter,  and  presented  a 
marked  contrast  to  his  former  emaciation.  The  cough  was  gone  ; 
he  slept  soundly  at  night,  perspiring  a  little,  especially  about  the 
nose  and  mouth.  The  bowels  remained  costive,  and  the  motions 
hard,  but  they  contained  very  much  less  mucus,  although  there 
were  still  a  few  threadworms  in  the  stools  after  each  powder,  and 
occasional  pains  in  the  belly  were  still  complained  of.  The  tongue 
was  much  pinker,  and  had  lost  in  a  great  measure  its  slimy  look." 

We  sometimes  find  that  after  the  treatment  has  been  continued 
for  a  certain  time,  the  improvement  becomes  less  rapid  or  even 
ceases.  When  this  occurs  it  is  advisable  to  change  from  alkaline 
to  acid  medicines.  The  necessity  for  the  change  seldom  however 
occurs  before  the  tongue  has  in  a  great  measure  lost  its  slimy 
appearance,  and  mucus  has  almost  ceased  to  be  seen  in  the  stools. 

In  such  cases  it  is  best  to  begin  with  alum,  as  in  the  following 
mixture : — 

^.  Aluminis,  Qij  ; 

Potas.  sulpbatis,  gij ; 

Acidi  sulpliurici  aromat.,  3j  ; 

Syrupi,  §j  ; 

Aq.  destil.  ad  giv.     M.     §ss  ter  die. 

To  this  after  a  short  time  sulphate  of  iron  can  be  added  in  doses 
of  three  or  four  grains.    Other  acid  preparations  may  also  be  used 


168  MUCOUS    DISEASE. 

as  the  liquor  ferri  pernitratis,  with  dilute  nitric  acid,  in  bitter 
infusion ;  quinine,  with  dilute  nitric  acid,  &c. 

If  there  be  much  emaciation,  cod-liver  oil  is  always  useful,  given 
in  small  doses  directly  after  meals. 

Change  of  air  is  also  of  much  service.  Eemoval  to  a  bracing 
seaside  air,  such  as  that  of  Brighton  or  Margate,  will  often,  after 
a  very  short  stay,  produce  a  very  great  improvement  in  the  symp- 
toms and  general  appearance  of  the  child. 


CHAPTBE    YII. 

WOEMS. 

Worms.  — Varieties — Description — Oxyuris  vermicularis — Ascaris  lumbricoides — 
Tricoceplialus  dispar — Tsenia  solium — Taenia  medio-canellata  —  Botlirioce- 
phalus  latus — Development  and  mode  of  obtaining  admission  into  human 
body. 

Symptoms. — Due  principally  to  the  accompanying  derangement  of  stomach  and 
bowels — Emaciation — Pain — Disturbance  of  nervous  system — Convulsions — 
Symptoms  when  digestive  deraugement  is  trifling — Migrations  of  worms — 
Special  symptoms  with  each  variety  of  worm. 

Diagnosis. — From  tuberculosis — From  tubercular  meningitis. 

Treatment. — Two  objects — To  expel  worms — Different  remedies  required  for  each 
variety — Purgatives — Enemata — Santonine — Turpentine — Oil  of  male  fern — 
To  restore  the  healthy  condition  of  alimentary  canal — Treatment  of  prolapsus 
ani. 

The  varieties  of  parasitic  worms  found  in  children  are : — 

Nematodes — 

Oxyuris  vermicularis,  the  small  threadworm. 
Ascaris  lumbricoides,  the  long  round  worm. 
Tricoceplialus  dispar,  the  long  threadworm. 

Cestodes — 

Tsenia  solium,  the  common  tapeworm. 

Tsenia  medio-canellata. 

Boihriocephalus  latus,  the  broad  tapeworm. 

Of  these  the  two  first  mentioned  varieties  are  by  far  the  most 
common  species  found  in  the  child.  The  taenia  is  rare  in  children 
under  the  age  of  six  years,  and  the  bothriocephalus  is  seldom  seen 
in  England,  although  common  enough  in  Switzerland  and  Eussia. 
When  found  in  this  country,  it  is  usually  in  persons  who  have  re- 
sided abroad. 

Description.^  — The  Oxyuris,  or  Ascaris  vermicularis,  belongs  to 

'  The  description  of  these  worms  is  borrowed  from  Dr.  Cobbold's  work  on 
Entozoa,  royal  8vo.,  London,  1864. 


170  WORMS. 

the  order  Nematoda.  The  male  measures  one-sixth  of  an  inch  in 
length,  and  its  caudal  extremity  is  obtusely  pointed.  The  female 
is  from  a  third  to  half  an  inch  in  length,  and  has  a  long,  gradually 
tapering  capillary  tail  which  terminates  in  a  three-pointed  end. 
This  has  been  supposed  to  act  as  a  kind  of  holdfast. 

Both  sexes  have  a  more  or  less  fusiform  body,  the  anterior  end 
being  narrowed  to  form  a  somewhat  abruptly  truncated  head. 
The  mouth  is  tripapillated,  leading  into  a  triangular  oesophagus. 
The  integument  is  transversely  striated,  and  is  of  a  silvery  white 
color.  The  penis  is  single,  simple,  and  very  minute.  The  eggs 
are  long,  un symmetrical,  and  measure  about  ,  4'ot5  in.  from  pole  to 
pole,  and  ^^^  in.  in  the  greatest  transverse  diameter. 

The  seat  of  the  worms  is  the  lower  part  of  the  colon,  especially 
the  sigmoid  flexure.  They  are  not  found  in  infants  at  the  breast, 
unless  other  food  is  being  given  at  the  same  time  with  the  breast- 
milk,  but  are  exceedingly  common  in  older  children. 

The  Ascaris  lumhricoides,  also  a  nematode,  is  much  larger  than 
the  preceding.  The  male  measures  from  four  to  six  inches  long, 
the  female  from  ten  to  fourteen.  The  body,  smooth,  fusiform,  and 
elastic,  is  marked  by  fine  transverse  rings,  and  tapers  gradually 
towards  either  extremity.  The  mouth  is  tripapillated ;  the  tail  is 
obtusely  pointed.  The  male  is  distinguished  from  the  female  by  a 
double  penis,  and  by  the  arcuate  form  of  its  tail.  The  female  is 
broader  than  the  male,  being  about  a  quarter  of  an  inch  in  diame- 
ter. 

These  worms  inhabit  principally  the  small  intestine,  but  often 
pass  into  the  stomach  and  other  parts  of  the  alimentary  canal. 
They  are  most  common,  according  to  Guersant,'  between  the  ages 
of  three  and  ten  years.  Their  number  varies  from  two  or  three 
to  twenty,  thirty,  or  even  more ;  they  are  seldom  solitary. 

The  Tricocephalus  dispar  is  not  very  common  in  England,  but  is 
sometimes  found  after  convalescence  from  typhoid  fever.  The 
male  measures  an  inch  and  a-half  in  length,  the  female  two  inches. 
This  worm  is  specially  characterized  by  an  extremely  long  filiform 
neck,  which  occupies  about  two-thirds  of  the  length  of  the  body. 
The  surface  of  the  skin  is  smooth  to  the  naked  eye,  but  when 
magnified  is  found  to  have  on  one  side  a  longitudinal   band  of 

'  Quoted  in  Valleix,  "Guide  du  Medecin  Practicicn,"  quatri^me  edition,  Paris, 
1800. 


CESTODES.  171 

minute  wart-like  papillae,  at  the  borders  of  whicli  the  ordinary 
circular  striae  of  the  integument  terminate.  The  tail  of  the  male 
worm  is  curved,  and  has  at  the  extremity  a  short  tabular  penis- 
sheath  armed  with  minute  retroverted  spines.  The  tail  of  the 
female  is  straight  and  blunt-pointed. 

The  worm  inhabits  chiefly  the  caecum  and  the  colon. 

The  Tsenia  solium  belongs  to  the  order  Cestoda.  Its  length  is 
very  great,  often  ten,  twenty,  thirty  feet,  or  even  more.  In  breadth 
it  is  about  a  third  of  an  inch  at  its  widest  part.  The  head  globu- 
lar and  about  the  size  of  the  head  of  a  small  pin,  is  produced  in  front 
so  as  to  form  a  short  cylindrical  proboscis,  which  is  armed  with  a 
double  crown  of  hooks  numbering  from  twenty-two  to  twenty- 
eight  in  each  circular  row.  The  head  is  also  furnished  with  four 
sucking  disks,  situated  at  the  four  angles.  The  neck  is  very  nar- 
row, and  is  about  half  an  inch  in  length ;  it  is  continued  into  the 
anterior  part  of  the  body,  which  is  sexually  immature,  and  presents 
only  traces  of  segmentation  in  the  form  df  fine  transverse  lines. 
These  lines  become  gradually  more  and  more  widely  separated, 
having  short  interspaces ;  and  eventually  the  imperfect  segments 
become  more  distinctly  marked,  and  true  joints  are  seen.  The 
earliest  formed  immature  joints  are  very  narrow ;  and  it  is  not 
until  about  the  four  hundred  and  fiftieth  segment  from  the  head 
that  they  become  sexually  mature.  The  mature  segment  is  called 
"  pro-glottis."  The  total  number  of  joints  in  a  worm  ten  feet  long, 
is  about  eight  hundred.  A  mature  pro-glottis  is  about  twice  as 
long  as  it  is  broad.  It  is  comparatively  thin  and  transparent,  and. 
is  furnished  with  a  branched  uterus,  which  consists  of  a  central 
longitudinal  stem,  giving  off  from  seven  to  ten  branches  on  either 
side.  Each  joint  has  a  common  reproductive  papilla  placed  at  the 
border  on  one  side  below  the  middle  line,  but  not  uniformly  to 
the  right  or  left  series.  The  male  orifice  is  above  the  vaginal 
outlet.  The  penis  is  sickle-shaped.  The  Taenia  solium  is  usually 
solitary.  It  is  seldom  seen  in  children  under  three  years  old.  Its 
seat  is  the  small  intestine. 

The  Txnia  medio -canellata  resembles  the  preceding  in  every  re- 
spect except  in  the  head.  The  cylindrical  proboscis,  and  the  double 
crown  of  hooks  being  absent. 

The  Bothriocejphalus  latus  is  the  largest  of  the  cestode  worms 
which  infest  the  human  body.  In  length  it  is  often  five-and-twenty 
feet,  and  it  is  about  an  inch  in  breadth. 


172  WORMS. 

The  head  measures  one  twenty-fifth  of  an  inch  in  breadth,  is 
blunt  at  the  top,  elongated,  and  slightly  flattened  from  behind 
forwards.  It  is  furnished  with  two  laterally  disposed  slit-like 
grooves,  but  is  destitute  of  hooks.  The  anterior  segments,  which 
are  sexually  immature,  are  extremely  narrow,  and  enlarge  very 
gradually  from  above  downwards.  After  reaching  their  greatest 
width  in  the  centre  of  the  body,  they  begin  gradually  to  decrease 
in  width,  but  increase  in  depth ;  so  that  while  in  the  central  seg- 
ments the  width  is  much  greater  than  the  depth,  being  as  one  inch 
to  one-eighth  of  an  inch,  in  the  joints  near  the  caudal  extremity, 
the  breadth  and  the  depth  are  about  equal,  being  frequently  a 
quarter  of  an  inch  in  either  measurement.  The  body  is  flattened, 
but  not  so  uniformly  as  is  found  in  the  Taenia  solium,  as  it  is 
rather  thicker  in  the  centre  than  at  the  sides.  The  total  number 
of  joints  has  been  estimated  at  about  four  thousand,  the  first  sex- 
ually mature  one  being  the  six-hundredth  from  the  head. 

The  reproductive  orifices  are  in  the  middle  line  towards  the 
upper  part  of  the  segment  on  the  ventral  aspect.  The  vaginal 
aperture  is  immediately  below  the  male  outlet,  and  both  openings 
are  surrounded  by  papillas-form  eminences.  The  uterus  consists  of 
a  single  tube,  often  folded  regularly  upon  itself  so  as  to  form  an 
opaque  centrally-disposed  rosette-like  mass. 

The  embryo  is  ciliated  and  moves  freely  about  in  water. 

The  mode  in  which  these  different  worms  obtain  admission  into 
the  human  body  is  not  well  understood.  It  appears  probable, 
however,  that  in  the  case  of  the  Ascaris  lumbricoides  the  drinking 
of  impure  unfiltered  water  is  the  ordinary  method  of  admission. 
With  regard  to  this  worm,  M.  Davaine^  states  that  the  ova  never 
become  developed  in  the  human  intestine,  but  are  expelled  from  it 
in  large  quantities.  The  yelk  does  not  at  once  undergo  segmenta- 
tion, and  consequent  embryonic  formation  ;  but  remains  unaltered 
in  the  waters  into  which  it  is  carried  for  six,  seven,  or  more 
months. 

After  the  embryo  has  been  formed,  it  remains  inclosed  in  the 
egg  until  it  gains  access  to  the  body,  when,  the  shell  being  softened 

'  C.  Davaine,  Recherches  sur  le  Developpement  et  la  Propagation  da  Tricoce- 
pbale  de  I'Horame  et  de  I'Ascaride  Lombricoide.  Comptes  Rendus  a  I'Academie 
des  Sciences,  t.  xlvi.,  21  Juin,  1858. 


DEVELOPMENT    OF    THE    T^NIA.  173 

by  the  intestinal  secretions,  it  pierces  the  egg  and  undergoes  further 
development  in  the  bowel. 

It  appears  from  M.  Davaine's  experiments,  that  the  development 
of  the  embryo  is  not  aided  by  heat,  neither  was  it  found  to  be 
prevented  by  immersion  of  the  egg  for  several  days  in  the  gastric 
juice  of  rabbits  or  dogs. 

The  development  and  migrations  of  the  Taenia  solium  have  been 
described  by  Dr.  Cobbold.^  In  this  worm  each  pro-glottis,  or  ma- 
ture segment,  is  furnished  with  male  and  female  reproductive 
organs.  When  this  has  become  impregnated,  by  contact  with 
another  pro-glottis,  eggs  are  formed  in  it.  In  each  egg  is  de- 
veloped an  embryo  which  remains  unhatched  as  long  as  the  ovum 
remains  in  the  body  of  the  parent.  The  segment,  after  its  ex- 
pulsion from  the  bowel,  moves  about  for  a  time  until  it  bursts  from 
the  growth  of  the  embryos  in  its*  interior,  and  the  ova  escape. 
Each  embryo  is  provided  with  a  boring  apparatus,  having  three 
pairs  of  hooks  at  its  anterior  end.  The  embryo  being  eaten  by 
some  animal,  as  a  pig,  or  a  rabbit,  breaks  its  shell,  and,  boring 
through  the  intestinal  wall  of  the  animal,  lodges  itself  in  the  fatty 
parts  of  the  flesh.  It  then  drops  its  hooks  and  becomes  the  well 
known  Cysticercus  cellulosce.  "When  the  flesh  of  an  animal  con- 
taining the  cysticercus  is  eaten,  the  parasite  attaches  itself  to  the 
wall  of  the  bowel,  and  grows  from  its  lower  or  caudal  extremity. 

It  appears,  therefore,  that  flesh  infested  with  the  cysticercus,  is 
the  ordinary  source  from  which  the  tasnise  are  derived.  Pigs  are 
very  liable  to  be  so  infested,  and  in  rabbits  it  is  exceedingly  com- 
mon, very  few  of  these  animals  being  found  altogether  free  from 
tapeworm.     In  these  animals  it.  is  the  Taenia  solium. 

Oxen  are  sometimes  infested  with  the  embryo  of  the  Tasnia 
medio  canellata ;  and  in  children  treated  for  chronic  diarrhoea  upon 
the  raw  meat  plan,  and  who  become  in  consequence  affected  with 
tapeworm,  as  is  said  sometimes  to  happen,  it  is  to  this  worm  that 
their  symptoms  are  due.  The  drinking  of  impure  water  may  pos- 
sibly convey  the  embryo  into  the  system,  as  is  the  case  with  the 
Ascaris  lumbricoides ;  for  M.  Marteau  de  Granvilliers,^  writing  in 
1762,  states  that  taenia  was  a  common  disease  at  that  time  in  a  cer- 
tain district  in  Normandy ;  the  peasants  of  the  neighborhood 
drinking  habitually  the  water  from  deep  ponds. 

1  Entozoa,  by  S.  Cobbold,  M.   D.,  royal  8vo.,  London,  18(54. 

2  Jouin.  de  Med.,  Cliir.,  et  Pliaim.,  17(52,  t.  xvii.  p.  24. 


174  WORMS. 

Symi'itoms. — The  presence  of  worms  in  cliildren  is  usually 
accompanied  by  an  unhealthy  condition  of  the  alimentary  canal, 
Avhich  precedes  their  appearance,  and  continues  after  the  worms 
have  been  expelled.  Perhaps  few  of  the  symptoms — and  they  are 
very  numerous — which  are  found  while  the  worms  exist  in  the 
body  can  be  directly  attributed  to  the  presence  of  these  parasites, 
as  they  may  all  of  them,  or  nearly  all,  be  found  also  in  cases  where 
repeated  purgatives  have  convinced  us  that  worms  are  absent. 
They  are,  therefore,  probably  due  in  great  part  to  the  abdominal 
derangement  which  favors  the  development  of  the  entozoa. 

This  derangement  has  been  already  described  in  the  previous 
chapter. 

As  a  result  of  it,  nutrition  becomes  impaired,  and  the  child 
wastes.  The  face  becomes  puffy  and  pale ;  the  lower  eyelid  dark, 
and  sometimes  leaden-colored;  the  pupils  often  dilated.  There  is 
itching  of  the  nose  and  anus;  epistaxis  may  occur;  and  the  sense 
of  smell  is  occasionally  depraved  or  lost.  The  upper  lip  often 
swells ;  the  breath  is  fetid,  especially  in  the  mornings ;  and  saliva- 
tion is  sometimes  noticed,  the  saliva  running  from  the  mouth  on  to 
the  pillow  during  sleep. 

At  night  the  child  is  very  restless :  during  sleep  he  starts,  twitches, 
and  grinds  his  teeth ;  and  he  often  wakes  in  great  panic,  crying 
and  talking  wildly.  There  is  often  a  frequent,  dry,  troublesome 
cough,  a  symptom  considered  by  StolP  very  characteristic  of  the 
presence  of  worms ;  and  sighing,  sobbing,  and  hiccough  are  not 
uncommon. 

The  belly  is  swollen  and  hard.  Pain  in  the  abdomen  is  often 
complained  of,  the  pain  being  usually  confined  to  one  or  two  points, 
especially  about  the  umbilicus.  In  character  it  is  tearing  or  cutting, 
although  sometimes  it  is  merely  an  uneasy  creeping  sensation,  or 
a  feeling  of  cold  in  the  bowels.  The  pain  is  sometimes  felt  in  the 
chest. 

The  appetite  is  capricious.  At  one  time  there  is  constant  crav- 
ing, the  hunger  seeming  to  be  almost  insatiable :  at  others  the 
child  refuses  all  food,  and  great  anxiety  is  excited  by  the  difficulty 
found  in  persuading  him  to  take  nourishment.  Sudden  attacks  of 
nausea  may  come  on  with  sour  smelling  eructations,  and  vomiting 
may  occur  with  expulsion  of  worms  from  the  mouth.     Lumbrici 

1  Prjelectiones  in  Diversos  Morbos  Chrouicos.     Maximilian  Stol),  vol.  ii. 


GENERAL    SYMPTOMS.  175 

are  not  very  frequently  ejected  in  this  way.  The  bowels  are  much 
confined ;  the  constipation  yielding  readily  to  purgatives,  but 
returning  when  the  action  of  the  medicine  has  subsided.  Some- 
times there  is  tenesmus,  with  constant  ineffectual  desire  to  go  to 
stool ;  and  attacks  of  diarrhoea  are  very  liable  to  come  on,  with 
very  great  straining,  the  motions  passed  being  black,  slimy,  and 
extremely  offensive.  Micturition  is  often  painful  and  dififi.cult,  and 
the  urine  whitish  or  milky.  Discharges  of  mucus  may  take  place 
from  the  rectum,  and  in  female  children  from  the  vagina. 

The  pulse  is  often  small,  quick  or  slow,  and  irregular.  The 
temper  is  irritable,  or  the  child  is  sullen  and  morose.  Attacks 
of  syncope  are  sometimes  seen,  and  there  may  be  passing  delirium, 
or  even  profound  stupor.  Other  disordered  conditions  are  enu- 
merated as  resulting  from  the  presence  of  worms,  as  sudden  blind- 
ness ;  loss  of  voice  ;  squinting  or  fixed  state  of  the  eyes ;  vertigo  ; 
general  convulsions.  According  to  Dr.  Underwood,  an  attack  of 
convulsions,  accompanied  by  small  pulse  and  hiccough,  is  an  almost 
certain  sign  of  worms.^ 

As  the  majority  of  these  symptoms  are  due,  not  to  worms,  but 
to  the  condition  of  the  alimentary  canal  usually  accompanying  the 
parasites,  the  symptoms  are  severe  in  proportion  to  the  abundance  of 
the  mucous  flux.  If  this  be  copious,  digestion  is  very  greatly  inter- 
fered with,  nutrition  is  seriously  impaired,  and  all  the  symptoms 
arising  from  indigestion  and  irritability  of  the  nervous  system  are 
strongly  marked.  Worms  may,  however,  be  found  in  children  in 
whom  the  alimentary  canal  is  almost  healthy.  The  general  symp- 
toms are  in  such  cases  exceedingly  trifling,  and  the  appearance  of 
the  tongue  differs  widely  from  that  described  in  mucous  disease.^ 
It  is  then  neither  flabby  or  slimy ;  but  is  small  and  pointed,  red- 
dish at  the  tip,  and  is  covered  on  the  dorsum  with  a  thin  curdy 
fur.  The  papillce  are  still  large,  but  are  less  conspicuous,  and 
their  outline,  instead  of  being  evenly  and  clearly  marked,  is  very 
irregular. 

Migration  of  worms  sometimes  takes  place.  They  may  pass 
out  of  the  alimentary  canal  into  passages  communicating  with  it, 
or  even  into  adjacent  organs  which  have  no  direct  communication 

'  Treatise  on  Diseases  of  Children,  edited,  with  additions,  hy  Henry  Davies, 
M.D.,  London,  1846,  10th  edition. 
*  See  page  157. 


176  WORMS. 

witli  thq  digestive  tube.  Thus  they  have  been  noticed  in  the  com- 
mon bile  duct,  and  in  the  gall  bladder,  in  two  cases  recorded  by 
M.  Guersant,^  where  the  children  died  suddenly  in  violent  convul- 
sions. They  have  also  been  seen  in  the  nasal  passages,  the  larynx, 
trachea,  the  larger  bronchi,  in  the  vagina,  and  even  in  the  urethra 
and  bladder.  Again,  worms  may  be  found  in  abscesses,  commu- 
nicating with  the  intestine,  having  escaped  from  the  bowel  by  per- 
forating the  wall,  or  by  entering  a  pre-existing  fistulous  opening. 
The  abscesses  are  generally  in  some  part  of  the  abdominal  wall, 
usually  the  umbilical  or  inguinal  regions,  or  in  the  substance  of 
the  liver.  It  is  said  that  an  artery  may  even  be  pierced  by  worms, 
and  a  case  is  reported  by  Mr.  Charcelay^  in  which  death  resulted 
from  this  cause. 

Certain  special  symplOTns  are  associated  with  different  varieties  of 
worms. 

The  Oxyuris  vermicularis  occasions  violent  itching  at  the  anus. 
This  is  most  marked  towards  the  evening,  and  the  irritation  not 
only  prevents  the  child  from  going  to  sleep,  but  may  be  so  intense 
as  to  produce  extreme  distress.  The  irritation  propagated  to 
neighboring  parts  may  excite  a  mucous  discharge  from  the  vagina, 
and  is  said  to  be  a  cause  of  masturbation. 

A  common  symptom  where  these  small  threadworms  are  present 
is  tenesmus,  the  desire  to  go  to  stool  being  frequent  but  ineffectual ; 
and  the  straining  may  cause  prolapsus  ani,  which  often  continues 
after  the  worms  have  been  expelled.  Besides,  the  irritation  pro- 
pagated over  the  whole  intestinal  tract  is  apt  to  give  rise  to 
diarrhoea.  Migration  of  the  oxyuris  occasionally  takes!place,  and 
cases  are  on  record  in  which  these  worms  were  found  in  the  vagina, 
uterus,  urethra,  oesophagus,  and  stomach. 

When  the  presence  of  the  oxyures  is  suspected  they  will  be  often 
found  on  examination  moving  about  in  the  radiating  folds  around 
the  anus. 

The  Ascaris  lumhricoides  gives  rise  to  pain  more  or  less  severe, 
situated  at  one  or  two  points  of  the  belly  in  the  neighborhood  of 
the  umbilicus.  Sudden  nausea  is  apt  to  occur  from  the  passage  of 
the  worm  into  the  stomach,  and  it  is  sometimes  expelled  by  the 

•  Quoted  by  M.  Valleix,  t.  iv.  p.  223,  4th  ed.     Paris,  1867. 
2  Quoted  by  MM.  Rillet  et  Bartliez,  Maladies  des  Eufauts,  t.  iii.  p.  867,  2d  ed. 
Paris,  1861. 


SPECIAL    SYMPTOMS.  177 

mouth.  The  lumbricus  is  more  apt  than  the  preceding  V9,riety  to 
give  rise  to  nervous  symptoms ;  and  vertigo,  convulsions,  chorea, 
&c.,  sometimes  seem  to  result  from  its  presence,  although  it  is  very 
difficult  to  estimate  the  exact  share  which  worms  take  in  the  pro- 
duction of  these  disorders.  How  much  is  due  to  the  irritation  of 
the  parasites,  and  how  much  to  the  general  irritability  of  the 
nervous  system  set  up  by  the  functional  derangement  of  the 
alimentary  canal,  is  a  question  which  it  is  not  easy  to  decide. 

The  irritation  of  the  lumbrici  may  give  rise  to  a  chronic  diar- 
rhoea, lasting  often  for  months.  The  motions  are  scanty,  offensive, 
of  the  color  and  consistence  of  thin  mud,  and  are  evacuated  with 
much  straining,  and  sometimes  prolapsus  ani.  They  are  more  fre- 
quent in  the  night  than  during  the  day.  A  child  of  three  years 
old  lately  came  under  the  writer's  notice,  who  had  suffered  for 
nearly  eight  months  from  persistent  looseness  of  the  bowels.  The 
diarrhoea  ceased  after  the  expulsion  of  twelve  lumbrici. 

Migration  of  the  lumbricus  may  occur,  and  in  cases  where 
penetration  of  the  wall  of  the  intestine  has  taken  place,  and 
abscesses  containing  worms  have  formed  under  the  integument  of 
the  belly,  the  worms  belonged  to  this  variety. 

The  tsenise  produce  sensations  of  weight,  and  sometimes  of 
gnawing  in  the  belly,  rising  occasionally  to  severe  attacks  of  colic, 
accompanied  by  considerable  swelling  of  the  abdomen,  especially 
about  the  umbilicus.  The  appetite  is  usually  large,  and  there  is 
progressive  emaciation,  which  is  more  marked  than  in  the  other 
varieties.  Vomiting  and  diarrhoea  are  rare.  Cephalalgia  is  not 
common,  but  when  it  occurs  it  is,  according  to  Louis,^  remarkably 
persistent.  The  same  author  remarked  in  the  majority  of  his 
cases  a  great  lassitude,  and  sometimes  cramps  in  the  extremities. 
Fragments  of  the  worm  are  passed  in  the  stools. 

With  the  presence  of  the  Tricocephalus  dispar  no  special  symp- 
toms have  been  associated. 

Diagnosis. — The  only  satisfactory  proof  of  worms  is  their  pre- 
sence in  the  stools :  any  symptom  or  any  combination  of  symptoms 
may  be  produced  by  other  diseases,  so  that  a  purgative  becomes 
the  crucial  test.  It  must  be  remembered,  however,  that  although 
worms  may  be  present,  it  does  not  necessarily  follow  that  they 

•  Du  Tenia  et  de  son  Traitement  par  la  Potion  Darbon.     Memoires  ou  Reuher- 
clies  Auat.-path.     Paris,  1826. 

12 


178  WORMS. 

have  been  the  cause  of  the  symptoms  for  which  advice  is  required. 
Tuberculosis,  rickets,  or  other  constitutional  diseases  may  exist  at 
the  same  time,  the  presence  of  the  entozoa  being  an  accidental  and 
often  a  trifling  complication.  In  such  cases  the  symptoms  will 
continue  after  the  worms  have  been  expelled. 

The  facts  appear  to  be,  that  the  large  majority  of  the  symptoms 
are  due  to  the  derangement  of  the  stomach  and  bowels  which  is 
almost  always  associated  with  the  parasites,  and  of  which  they 
appear  to  be  rather  a  result  than  a  cause,  although,  no  doubt,  the 
irritation  they  excite  tends  to  encourage  the  derangement.  When 
the  mucous  membrane  of  the  alimentary  canal  is  in  a  healthy  state 
there  is  no  nidus  for  worms,  and  it  appears  probable  that  a  favor- 
able medium  is  essential  to  their  development  in  any  quantity. 
The  required  nidus  is  found  in  the  alkaline  mucus  which  is  so 
abundantly  secreted,  and  in  this  they  develop  very  rapidly.  It  is 
more  important  to  detect  the  presence  of  some  worms  than  of 
others.  The  taeniae  produce  very  great  emaciation ;  and  the  lum- 
brici,  if  present  in  large  numbers,  may  cause  serious  interference 
with  nutrition  ;  but  the  oxyures  are  of  comparatively  little  moment, 
and  unless  the  irritation  be  so  great  as  to  prevent  sleep  are  seldom 
attended  with  any  great  inconvenience. 

The  symptoms  attending  the  presence  of  worms  may  be  so 
severe  as  to  give  rise  to  suspicion  of  the  formation  of  tubercle. 
Thus,  if  a  child  has  irregular  attacks  of  fever ;  begins  to  lose  flesh  ; 
sleeps  badly,  grinding  his  teeth  at  night ;  becomes  pale  and  heavy- 
eyed  ;  loses  his  cheerfulness,  and  gets  languid  and  dull;  has  a 
capricious  appetite,  being  sometimes  ravenous,  and  at  other  times 
showing  a  disgust  for  food,  with  bowels  alternately  relaxed  and 
constipated  ;  in  such  a  case  the  existence  of  tuberculosis  might  be 
suspected.  If,  however,  the  symptoms  are  due  to  worms,  an  active 
purgative  will  give  evidence  of  their  presence,  and  by  clearing 
away  a  quantity  of  the  tenacious  mucus  will  cause  an  immediate 
improvement  in  the  symptoms:  afterwards  suitable  remedies  and 
careful  diet  will  restore  the  alimentary  canal  to  a  healthy  condi- 
tion (see  diagnosis  of  mucous  disease,  page  161). 

In  other  cases,  where  the  nervous  symptoms  are  well  marked, 
and  are  accompanied  by  a  dilatation  of  the  pupils,  vomiting  of 
watery  fluid,  constipation,  and  a  slow,  irregular  pulse,  tubercular 
meningitis  may  be  suspected.  Here,  however,  the  fact  that  signs 
of  digestive  derangement  have  preceded  the  nervous  symptoms, 


TEEATMENT.  179 

the  absence  of  beaclache,  the  readiness  with  which  the  constipation 
yields  to  a  mild  purgative,  and  the  appearance  of  worms  in  the 
stools,  will  clear  up  the  diagnosis.  Besides,  in  these  cases  a  history 
can  often  be  obtained  of  the  previous  occurrence  of  similar  attacks. 

In  cases  where  abdominal  pains  are  complained  of  by  children 
a  careful  examination  of  the  chest  should  always  be  made,  as  in 
them  the  pain  of  pleurisy  is  very  commonly  referred  to  the  belly, 
and  not  to  the  thorax. 

Treatment} — In  the  treatment  of  worms,  it  is  not  sufficient  to 
expel  the  parasites  from  the  body,  for  so  long  as  the  unhealthy 
condition  of  the  alimentary  canal  continues  to  provide  a  nidus  for 
the  entozoa  they  will  be  frequently  found  to  be  reproduced  again 
and  again  as  often  as  they  are  driven  out.  There  are  therefore 
two  indications  to  fulfil  in  the  treatment  of  this  complaint,  viz : — 

To  expel  the  worm. 

To  destroy  the  nidus  by  restoring  the  alimentary  canal  to  a 
healthy  condition. 

To  expel  the  worms,  different  measures  must  be  employed,  ac- 
cording to  the  variety  of  worms  to  be  attacked. 

The  oxyures,  which  inhabit  the  rectum  and  sigmoid  flexure,  are 
within  the  reach  of  injections,  and  are  best  treated  by  this  means. 
Different  enemata  may  be  used  ;  thus,  four  or  five  ounces  of  strong 
infusion  of  quassia,  to  which  twenty  drops  of  tinct.  ferri  sesqui- 
chloridi  have  been  added ;  the  same  quantity  of  lime-water ;  or  a 
solution  of  one  drachm  of  common  salt,  dissolved  in  five  ounces  of 
distilled  water,  may  be  administered.  A  correspondent  of  TJie  Lancet^ 
suggests  an  injection  of  two  scruples  of  aloes,  rubbed  up  with  half 
a  pint  of  lime-water.  Whatever  form  of  enema  be  used,  it  should 
be  given  at  bedtime,  should  be  used  tepid,  and  should  be  pre- 
ceded by  a  large  injection  (30  oz.)  of  warm  soap  and  water,  so  as 
to  empty  the  colon  as  thoroughly  as  possible. 

The  diarrhoea  which  is  so  common  when  the  oxyures  are  present 
is  readily  arrested  by  a  purgative,  as  castor  oil,  or  the  following 
powder : — 

;^.  Pulv.  jalapse,  gr.  v  ; 

Pulv.  aloes  Socotrinse,  gr.  j ; 

Pulv.  scammonise,  gr.  v.     Ft.  Pulv.     Primo  mane  sumendus. 

'  All  the  prescriptions  given  in  this  chapter  are  adapted  to  a  child  of  four 
years  old. 

2  Lancet,  April  18,  18G8. 


180  WORMS. 

This  powder  should  be  given  every  second  or  third  morning, 
and  every  evening  the  injection  should  be  repeated,  until  no  trace 
of  the  worms  is  found  in  the  stools  or  in  the  returning  enema. 

Great  irritation  of  the  rectum  may  be  allayed  by  the  injection  of 
an  ounce  of  thin  warm  starch,  containing,  if  necessary,  a  few  drops 
of  laudanum,  before  the  child  is  put  to  bed;  or  a  towel  wetted  with 
cold  water  may  be  applied  to  the  fundament  while  in  bed,  as  re- 
commended by  Sir  Thomas  Watson. 

For  the  lumhricus  and  the  iricocephalus  dispar  the  best  remedy  is 
santonine,  which  may  be  given  either  alone  or  combined  with  pur- 
gatives.    A  good  combination  is  the  following : — 

^.  Santonini,  gr.  xv  ; 
Pulv.  zingib.,  gr.  v  ; 
Pulv.  jalapse,  .^ss ; 
Sulphuris  loti,  5jss  J 
Conf.  sennae,  §j.     M.     Ft.  confectio. 

Of  this  confection  a  teaspoonful  should  be  given  two  or  three  times 
a  day.  Or  it  may  be  usefully  combined  with  aloes,  as  in  the  fol- 
lowing mixture: — 

^.  Santonini,  ^ss  ; 

Mucilag.  acacise,  ^j  ; 
Decocti  aloes  co.  ad  ^vj.     M. 
Ft.  mistura.     gij  ter  die  sumend. 

When  given  alone,  santonine  may  be  conveniently  administered 
sprinkled  on  a  slice  of  bread  and  honey,  in  doses  of  one  or  two 
grains,  twice  or  thrice  in  the  day.  In  such  cases  an  occasional  ape- 
rient will  be  required  to  carry  off  the  dead  worms. 

Santonine  usually  increases  the  flow  of  urine,  and  may  give  a 
reddish  tint  to  that  secretion.  Another  effect  sometimes  found  to 
be  produced  by  the  drug  is  a  peculiar  perversion  of  the  sight,  in 
which  all  objects  are  seen  of  a  green  color.  This  symptom  is  of 
no  importance,  and  readily  passes  away  when  the  drug  is  omitted, 
but  it  is  well  to  warn  parents  of  its  liability  to  occur. 

Many  other  drugs  have  been  recommended  for  the  expulsion  of 
these  worms ;  thus  mercury,  antimony,  granulated  tin,  nitrate  of 
silver,  and  arsenic ;  kamala,  kousso,  assafoetida,  tannin,  valerian, 
and  Corsican  moss ;  all  these  drugs,  alone  or  variously  combined, 
have  been  used  and  found  successful  in  these  cases.  Cowhage  (the 
hairs  of  the  Mucuna  pruriens)  is  strongly  recommended  by  Dr. 


TREATMENT  OF  TAPEWORM.  181 

Dunglison,'  and  can  be  given  in  doses  of  half  a  drachm  to  a  drachm 
twice  a  day,  in  syrup  or  treacle.  Dr.  W.  Roe'^  advises  the  use  of  bi- 
sulphite of  soda,  ten  grains  three  times  a  day  in  distilled  water  with 
tinct.  aurantii.  The  bisulphite  to  be  preceded  by  an  alkali.  If  the 
drug  employed  is  not  in  itself  purgative,  it  is  well  to  combine  it  with 
some  aperient,  or  at  any  rate  to  act  gently  upon  the  bowels,  from 
time  to  time,  so  long  as  the  remedy  is  in  use.  Violent  purgatives 
are  not  needed  in  these  cases,  the  repeated  action  of  mild  aperients 
being  equally  efficient  in  causing  expulsion  of  the  worms  without 
exciting  so  much  irritation  of  the  digestive  canal. 

The  treatment  of  the  tsenise  varies  according  to  the  age  and 
strength  of  the  child.  If  he  is  young  and  weakly,  cowhage  may 
be  given,  as  recommended  for  lumbrici,  with  an  occasional  aperi- 
ent, as  castor  oil,  or  the  purgative  powder  given  above.  Powdered 
pomegranate  bark  is  also  very  useful,  and  may  be  given  in  doses 
of  five  grains,  in  treacle,  every  four  hours ;  or  a  decoction  of  the 
dried  bark  may  be  used  instead. 

For  children  over  eight  years  old  Dr.  Davies^  recommends 
turpentine  to  be  given,  in  the  following  way : — 

^.  Olei  terebinthinse, 
Mellis, 

Mucilaginis  acaciae,  aa  5ss  ; 
Aq.  destil.  ad  §ss.     M. 

Ft.  haustus,  sexta  quique  hora  sumeadas ; 

and  every  second  day  a  powder  containing  calomel  combined  with 
pulv.  scammon.  co.  should  be  administered.  Dr.  Davies  states  that 
he  has  never  known  tsenige  in  children  resist  this  treatment. 

By  far  the  most  certain  and  effectual  drug  for  expelling  the 
tapeworm  is  the  oil  of  male  fern  ;  and  if  the  child  is  strong  enough 
to  bear  the  necessary  fasting,  the  following  method  seldom  fails. 
In  the  evening  a  dose  of  castor  oil  must  be  given ;  the  following 
morning,  after  the  bowels  have  been  well  relieved  by  the  aperient, 
the  oil  of  male  fern  is  to  be  given  in  the  following  draught : — 

1^.  Olei  filicis  maris,  3j  ; 
Syrupi, 

Mucilag.  acacise,  aa  ^ss  ; 
Aq.  cinnamomi,5J.     M.     Ft.  haustus. 

1  On  Diseases  of  the  Stomach  and  Bowels  in  Children.     London,  1824. 

2  See  Practitioner,  No.  10,  April,  1869. 

3  Dr.  Underwood's  Treatise  on  Diseases  of  Children,  10th  edition,  with  additions 
by  Henry  Davies,  M.D.     London,  1846. 


182  WORMS. 

After  three  hours  this  draught  must  be  followed  up  by  a  second 
dose  of  castor  oil.  The  draught  sometimes  causes  vomiting ;  if 
so,  a  second  must  be  administered.  An  important  part  of  this 
treatment  consists  in  the  fact  that  from  before  the  first  dose  of  the 
oil  until  after  the  worm  has  been  expelled,  somewhere  about  the 
middle  of  the  following  day,  no  food  of  any  kind  must  be  taken, 
and  no  drink,  except  water  in  small  quantities,  can  be  allowed. 
A  fast  of  fourteen  or  fifteen  hours  is  therefore  required ;  and,  in 
the  case  of  children,  this  cannot  always  be  borne.  As  the  tape- 
worm grows  from  the  head,  we  cannot  be  certain  that  the  entire 
worm  has  been  expelled  unless  the  head  is  found.  This  should, 
therefore,  always  be  carefully  searched  for  in  the  excretions. 

To  fulfil  the  second  indication  of  destroying  the  nidus,  recourse 
must  be  had  to  the  measures  recommended  in  the  preceding  chap- 
ter (see  mucous  disease).  The  diet  must  be  first  carefully  arranged, 
so  as  to  cut  off  all  articles  of  food  which  by  their  fermentation 
would  give  rise  to  acid  and  so  favor  the  abnormal  secretion  of 
mucus  in  the  bowels.  Alkalies,  aloes,  etc.,  should  then  be  pre- 
scribed, as  has  already  been  directed. 

The  treatment,  however,  must  be  varied  according  to  the  con- 
dition of  the  stomach  and  bowels,  and  need  not  be  pursued  in  all 
its  details  in  every  case  of  worms.  If  there  be  little  derangement 
of  the  alimentary  canal,  purgatives  or  injections  to  remove  the 
worms,  followed  by  a  tonic,  will  be  all  that  is  required.  It  is  only 
in  cases  where  the  secretion  of  mucus  is  in  great  excess,  and  the 
interference  with  digestion  and  assimilation  of  food  is  carried  to  a 
high  degree,  that  all  the  measures  given  above  are  required. 

The  prolajysus  am,  brought  about  by  the  great  straining  excited 
by  the  presence  of  worms,  usually  disappears  when  the  worms 
have  been  expelled.  Sometimes,  however,  it  remains  as  a  persist- 
ent condition.  In  such  cases  the  prolapsed  bowel  should  be 
sponged  with  warm  water  after  each  action  of  the  bowels,  and 
should  be  carefully  returned  by  gentle  pressure  with  the  thumbs 
covered  with  a  soft,  warm  napkin.  If  the  contraction  of  the 
sphincter  is  very  violent,  and  resists  the  return  of  the  protruded 
gut,  the  finger,  well  oiled,  should  be  introduced  into  the  bowel, 
and  should  be  passed  within  the  sphincter  so  as  to  carry  the  bowel 
with  it  above  the  contracting:  ring. 

Prolapse  may  often  be  prevented  by  placing  the  child  during 
defecation  in  such  a  manner  that  his  feet  do  not  touch  the  ground, 


TREATMENT    OF    PROLAPSUS    ANI.  183 

and,  at  tlie  same  time,  the  edge  of  the  anus  can  be  supported  by 
two  fingers. 

The  bowels  must  be  carefully  regulated  so  as  to  prevent  consti- 
pation and  consequent  straining.  The  child  should  be  warmly 
clothed,  with  a  flannel  bandage  round  the  belly,  and  should  take 
frequent  exercise  in  the  open  air. 

For  medicine,  a  drop  or  two  of  tinct.  opii  may  be  added  to  each 
dose  of  the  tonic  mixture;  and  twice  a  day  a  small  astringent 
injection  may  be  used,  as  decoction  of  oak-bark,  or  of  rhatany- 
root,  to  give  tone  to  the  relaxed  mucous  membrane,  and  remove 
the  tendency  to  prolapse. 

These  cases  seldom  give  much  trouble,  and  are  usually  readily 
cured. 


CHAPTEE    YIII. 

CHRONIC   TUBERCULOSIS. 

Tuberculosis. — A  diathetic  disease  attacking  the  organs  generally — May  be  acute 
or  chronic — Yellow  infiltrated  tubercle  of  Laennec  not  true  tubercle — Gray 
and  yellow  granulations  may  coexist  in  the  same  organ — Differences  between 
them — Changes  in  tubercle — The  tuberculous  and  scrofulous  types — Distinct, 
but  not  antagonistic. 

Symptoms. — Of  Chronic  tuberculosis — Shapes  of  chest. 

Diagnosis. — In  infants — Value  of  the  thermometer — In  older  children. 

Causes. — The  result  of  a  constitutional  tendency — Exciting  causes — Inoculation 
of  tubercle. 

Prevention.  Treatment. — Climate — Exercise — Fresh  air — Diet — Attention  to  di- 
gestive organs — Astringents — Alkalies — Cod-liver  oil  and  tonics  not  to  be 
given  too  early. 

Tuberculosis,  a  diathetic  disease  giving  rise  to  the  formation  of 
tubercle,  is  in  children  exceedingly  common.  Its  existence  is  indi- 
cated by  certain  general  symptoms.  Following  or  accompanying 
these  general  symptoms  are  other  local  symptoms,  showing  the 
presence  of  tubercle  in  one  or  more  organs  of  the  body,  and  the 
disease  is  then  called  pulmonary,  bronchial,  mesenteric,  phthisis, 
&c.,  according  to  the  organ  of  which  the  local  symptoms  predomi- 
nate. The  child  differs  from  the  adult  in  a  tendency  to  a  general 
formation  of  tubercle.  The  lungs  constantly  suffer,  but  they  do 
not  suffer  alone :  the  membrane  of  the  brain,  the  bronchial  and 
mesenteric  glands,  the  pleura,  peritoneum,  liver,  spleen,  in  fact  all 
the  organs  of  the  body  exhibit  a  nearly  equal  readiness  to  be  in- 
vaded by  this,  the  anatomical  expression  of  the  general  disease, 
and  to  suffer  simultaneously  from  the  same  morbid  condition.  The 
local  symptoms  are,  however,  usually  confined  to  one  or  two 
organs,  the  lesions  of  the  others,  less  severe,  or  less  noticeable,  being 
only  discovered  by  post-mortem  examination. 

Tuberculosis  may  be  either  acute  or  chronic  in  its  course.  When 
acute,  it  is  invariably  attended  by  the  development  of  miliary 
tubercles  in  the  organs  generally.     When  chronic,  the  same  result 


MILIARY    TUBERCLE.  185 

may  take  place;  but  sometimes  we  find  in  these  cases  early  symp- 
toms arising  from  the  lungs  with  evidence  of  consolidation,  and 
eventually  of  softening  and  excavation.  These  changes  are  found 
after  death  to  be  due  to  the  presence  of  a  morbid  yellow  material 
which,  differing  in  character  from  ordinary  miliary  tubercle,  is  re- 
garded by  many  pathologists  as  the  result  of  scrofulous  inflam- 
mation, and  hence  bears  the  name  of  scrofulous  pneumonia.  This 
material  is  the  infiltrated  yellow  tubercle  of  Laennec  and  his  fol- 
lowers. It  is  true  that  we  often  find  in  the  same  lung  every  degree 
of  pathological  formation  between  true  miliary  tubercle  and  the 
dense  masses  resulting  from  scrofulous  inflammation,  but  one  of  the 
results  of  miliary  tubercle  is  to  excite  inflammation  around  it : 
lobular  pneumonia  is  set  up,  and  the  deposit,  instead  of  becoming 
absorbed,  as  occurs  in  pulmonary  inflammation  attacking  a  consti- 
tutionally healthy  patient,  tends,  in  one  of  scrofulous  habit,  to 
soften,  break  down,  and  excite  ulceration  in  the  tissues  around. 
The  masses  will  accordingly  be  large  or  small,  according  to  the 
extent  of  pulmonary  tissue  involved  in  the  inflammation. 

Miliary  tubercle  occurs  in  two  forms,  the  gray  and  the  yellow 
granulation. 

Gray  granulations  consist  of  gray,  round,  hard,  elastic,  dense 
masses  about  the  size  of  a  millet  seed,  which,  on  section  of  the 
lung  are  found  projecting  from  the  cut  surface.  They  resist  pres- 
sure, and  are  not  easily  crushed  by  the  nail.  The  color  is  gray  and 
semi-transparent,  and  in  the  centre  they  often  contain  a  black  point 
or  a  small  quantity  of  yellow  tuberculous  matter. 

The  yellow  granulation  is  rather  larger  than  the  gray.  It  is  of 
a  bright  yellow  color,  and  on  pressure  is  not  crushed,  but  flattens 
out  like  recent  false  membrane.  It  is  evidently  the  result  of  de- 
generation of  the  gray  granulation,  for  every  stage  can  be  traced 
in  the  change  from  the  one  form  to  the  other.  The  gray  granula- 
tion first  turns  white :  an  opaque  yellow  spot  then  appears  in  the 
centre :  this  extends  until  the  whole  substance  is  converted  after  a 
time  into  a  yellow  mass.  This  degeneration  of  the  gray  granula- 
tion sometimes  goes  on  so  rapidly  that  the  tubercle  seems  to  have 
been  yellow  from  the  first,  the  processes  of  formation  and  of  degen- 
eration appearing  to  take  place  simultaneously.  Thus,  in  a  rickety 
child  of  twenty  months  old,  in  whom  death  took  place  from  acute 
tuberculosis  after  an  illness  of  seven  weeks,  the  lungs  were  found 
to  be  stuffed  with  miliary  yellow  tubercles,  none  of  which  were 


186  CHRONIC    TUBERCULOSIS. 

larger  than  a  hemp-seed,  the  greater  number  being  very  much 
smaller.  There  was  no  gray  tubercle  anywhere.  Usually,  how- 
ever, the  yellow  and  gray  granulations  coexist  in  the  same  lung. 
The  granulations,  scattered  at  first,  become  collected  together  as 
the  morbid  process  goes  on  more  rapidly,  so  as  to  form  masses  of 
tubercle  of  variable  form  and  size.  The  bulk  of  these  masses  is 
no  doubt  increased  by  the  occurrence  of  pneumonia,  the  deposit 
of  which  degenerating  and  becoming  yellow,  is  indistinguishable 
by  its  naked  eye  or  microscopic  characters  from  true  tubercle. 

Besides  the  lungs,  tubercles  are  found  in  the  parenchyma  of  solid 
organs,  as  the  liver,  spleen,  kidney,  brain,  &c.  They  may  also 
occupy  the  serous  and  mucous  membranes,  the  lymphatic  glands, 
the  bones,  muscles,  and  external  areolar  tissue.  In  the  case  of 
acute  tuberculosis,  the  greater  number  of  these  tissues  appear  to 
suffer,  and  are  found  after  death  studded  with  gray  granulations. 
When  the  disease  is  more  chronic,  several  of  them  may  escape : 
the  granulations  are  then  more  commonly  yellow,  and  are  often 
grouped  into  masses.  Occasionally  only  one  or  two  organs  are 
found  to  be  affected  with  tubercle,  but  this  is  the  exception.  In 
such  cases  the  tubercle  is  seated  in  the  lungs  and  the  bronchial 
glands,  these  two  organs  far  surpassing  the  others  in  their  proneness 
to  be  invaded  by  this  morbid  change.  The  processes  of  tubercular 
formation  and  degeneration  appear  to  go  on  with  greater  rapidity 
in  some  organs  than  in  others.  Thus,  it  is  not  uncommon  to  find 
in  the  same  subject  gray  granulations  in  the  liver,  yellow  granula- 
tions in  the  lungs,  and  in  the  lymphatic  glands  masses  of  yellow 
substance  resulting  from  the  aggregation  of  miliary  tubercles. 

The  difference  between  gray  and  yellow  tubercle  consists  in  the 
greater  proportion  of  fat  elements  contained  in  the  latter.  As  the 
fatty  degeneration  continues,  the  yellow  tubercle  becomes  softer 
and  softer,  the  softening  process  beginning  either  in  the  centre,  or 
at  a  point  on  the  surface,  and  being  very  much  influenced  by  the 
degree  of  softness  and  humidity  of  the  tissue  in  which  it  is  con- 
tained; the  more  yielding  and  the  moisterthis  may  be,  the  quicker 
does  the  change  take  place.  At  the  same  time  the  surrounding 
tissue  suppurates;  becomes  infiltrated  with  cheesy  matter,  the 
result  of  inflammation ;  and  a  cavity  containing  a  purulent  fluid 
is  formed,  the  consequences  resulting  from  which  vary  according 
to  the  organ  in  which  this  change  occurs. 

Sometimes  a  different  transformation  takes  place ;  the  tubercle, 


CONFORMATION    OF    BODY.  187 

instead  of  softening  into  a  purulent-looking  fluid,  shrinks,  and 
hardens  into  a  cretaceous  mass,  by  absorption  of  its  fluid  con- 
stituents. 

These  changes  will  be  more  fully  described  in  considering  the 
anatomical  characters  of  pulmonary  phthisis. 

Children  who  are  disposed  to  be  the  subjects  of  tuberculosis  are 
often  distinguished  by  certain  peculiarities,  which  are  held  to  con- 
stitute a  type  of  the  tuberculous  diathesis.  They  are  tall  for  their 
age  and  slightly  made ;  the  skin  is  delicate  and  transparent-looking, 
allowing  the  superficial  veins  to  be  distinctly  seen  ;  the  face  is  oval, 
and  the  features  generally  regular.  The  complexion  is  usually 
clear,  but  not  always ;  the  face  is  sometimes  covered  with  freckles  ; 
and  Dr.  Gee  is  of  opinion  that  amongst  the  poor  children  of  Lon- 
don the  existence  of  freckles  is  evidence  of  very  singular  value  of 
a  tubercular  tendency.^  These  children  are  often  remarkably 
good-looking,  with  large,  bright,  intelligent  eyes,  long  eyelashes, 
and  soft  silken  hair.  The  limbs  are  straight;  the  wrists  and 
ankles  small.  The  nervous  system  is  highly  developed,  and  the 
general  organization  delicate.  The  teeth  are  cut  betimes;  they 
walk  and  talk  early  ;  and  the  fontanelle  often  closes  before  the 
end  of  the  second  year. 

If  we  compare  this  type  of  body  with  the  peculiar  conformation 
considered  to  be  characteristic  of  the  scrofulous  diathesis,  we 
notice  remarkable  differences.  Here  the  face  is  more  rounded 
than  oval;  the  complexion  is  dull  and  pasty-looking;  the  skin 
thick  and  opaque.  The  face  is  not  so  comely  as  in  the  preceding 
type,  although  it  is  by  ho  means  necessarily  ill-favored ;  the  features 
are  large ;  the  lips  full ;  the  alse  of  the  nose  thick  ;  and  the  nostrils 
expanded,  so  that  the  nose  looks  broad.  The  tongue  is  often  large. 
The  ends  of  the  long  bones  are  full,  and  their  shafts  thick.  The 
fingers  are  often  clubbed.  The  belly  is  large  and  prominent.  In 
such  children  there  is  great  activity  of  all  the  epithelial  structures. 
The  hair  and  nails  grow  rapidly  ;  the  skin  generally  is  rough  and 
scaly  ;  and  there  is  often  a  remarkable  development  of  hair,  which 
is  seen  as  a  thick  down  on  the  forehead,  cheeks,  ears,  and  along 
the  spine.  There  is  constant  secretion  from  the  nose;  the  skin 
about  the  lips  is  subject  to  crack,  and  to  become  sore ;  the  eyes 

'  Quoted  from  a  Clinical  Lecture  on  Phthisis,  delivered  by  Dr.  Gee,  at  the  Or- 
mond  Street  Hospital  for  Sick  Children. 


188  CHROXIC    TUBERCULOSIS. 

often  look  weak,  even  when  not  inflamed ;  and  there  is  great  ten- 
dency to  ophthalmias,  inflammation  of  tarsi,  catarrhs,  certain  skin 
diseases,  irritation  and  inflammation  of  the  lymphatic  glands,  to 
caries  of  bone,  and  to  a  low  form  of  pneumonia. 

These  two  types  of  body  are  very  distinct,  but  they  are  not 
antagonistic.  Tubercular  formation  may  occur  as  an  accompany- 
ing phenomenon  of  either,  and  either  may  be  marked  by  that  form 
of  pulmonary  phthisis  known  by  the  name  of  scrofulous  pneumonia; 
but  of  the  two,  in  the  tuberculous  diathesis  there  is  an  especial 
tendency  to  the  former  disease  ;  in  the  scrofulous  diathesis,  to  the 
latter. 

Symptoms. — Tuberculosis  may  be  acute  or  chronic  in  its  course. 
With  the  acute  form  we  have  in  the  present  volume  nothing  to 
do :  the  attack  having  all  the  ordinary  characters  of  an  acute  dis- 
ease— irregular  febrile  disturbance,  more  or  less  high ;  rapid 
emaciation;  great  depression  of  strength  and  spirits;  ending,  in 
the  large  majority  of  cases,  after  a  few  weeks,  in  death,  if  the  dis- 
ease be  severe — in  recovery,  if  it  be  mild,  without  any  satisfactory 
evidence  of  local  change.  In  some  cases,  however,  there  is  locali- 
zation of  the  disease  in  some  particular  organ,  and  a  lapse  into 
chronic  phthisis. 

The  acute  and  the  chronic  forms  of  tuberculosis  are  not  sepa- 
rated by  any  well-defined  limits,  but  between  them  there  are 
infinite  gradations  depending  upon  the  intensity  of  the  fever,  the 
length  of  time  the  disease  lasts,  and  the  rapidity  with  which  local 
symptoms  arise  to  show  that  some  particular  organ  is  more  espe- 
cially affected  than  the  others,  or  is  more  sensitive  to  the  changes 
which  are  taking  place  within  it.  The  chronic  form  may  not 
remain  chronic,  but  may  suddenly  assume  an  acuter  type,  or  may 
appear  to  do  so  from  the  occurrence  of  some  inflammatory  com- 
plication. 

When  the  disease  is  chronic  from  the  first,  one  of  the  earliest 
symptoms  is  a  want  of  healthy  color  of  the  face,  which  soon  be- 
comes distinct  pallor.  The  child  is  listless ;  he  still  continues  to 
play  at  his  accustomed  amusements,  but  does  so  without  spirit, 
and  quickly  tires.  His  flesh  becomes  flabby,  and  he  soon  begins 
to  waste.  He  complains  of  no  pain,  and  when  questioned  merely 
says  he  is  "tired."  The  appetite  continues  good,  and  thirst  is  not 
very  marked,  although  at  night  he  may  wake  up  and  ask  for 
drink.     Digestion  seems  well  performed,  and  the  evacuations  are 


SYMPTOMS.  189 

natural.  At  night  he  may  get  a  little  feverish,  especially  about 
the  palms  of  the  hands  and  the  soles  of  the  feet,  which  feel  dry 
and  hot,  but  he  sleeps  well  and  tranquilly,  although  in  the  morn- 
ing he  shows  some  unwillingness  to  leave  his  bed. 

In  children  in  whom  the  diathesis  is  marked,  the  shape  of  the 
chest  is  often  peculiar.^  The  lungs  being  small,  relatively  and 
absolutely,  the  wall  of  the  chest  is  obliged  to  adapt  itself  to  the 
size  of  its  contents.  The  thorax  is  consequently  elongated.  'The 
ribs  are  exceedingly  oblique,  the  sixth,  seventh,  eighth,  and  ninth, 
in  particular,  passing  very  much  downwards,  and  their  cartilages 
very  much  upwards,  so  that  the  angle  of  union  is  unnaturally 
acute.  The  four  uppermost  intercostal  spaces  are  widened  next 
to  the  sternum.  The  four  lowest  are  almost  obliterated  by  ap- 
proximation of  their  ribs.  The  diaphragm  is  unusually  arched, 
for  it  retains  its  natural  level  while  its  attached  margin  is  lowered, 
and  a  certain  number  of  the  ribs,  often  from  the  eighth  to  the 
twelfth,  lie  for  the  greater  part  of  their  extent  in  contact  with  the 
diaphragm  without  any  lung  underneath  them.  In  addition  to  the 
lengthening  of  the  chest,  two  different  shapes  of  thorax  are  found, 
according  to  the  condition  of  the  cartilages;  if  these  remain  firm, 
the  chest  is  long  and  almost  circular ;  if  they  are  soft,  it  is  flattened 
from  before  backwards. 

A  third  variety  of  shape  is  a  form  of  the  pigeon-breasted  thorax. 
It  is  the  result  of  repeated  catarrhs  affecting  the  lower  lobes  of 
children  in  whom  the  lungs  are  small.  Air  being  unable  during 
the  catarrh  to  obtain  ready  access  into  the  lower  lobes,  the  inferior 
ribs  are  driven  inwards  at  each  descent  of  the  diaphragm.  The 
sternum  is  thus  carried  fowards,  the  degree  of  protrusion  depending 
upon  the  height  to  which  the  impediment  to  the  entrance  of  the 
air  extends  into  the  bronchi. 

This  form  of  pigeon-breasted  thorax  is  distinguished  from  the 
pigeon-breast  so  common  in  rickets  by  the  different  shape  of  the 
upper  part  of  the  chest  in  the  two  diseases.  In  rickets,  all  the  ribs 
being  softened,  the  deformity  extends  as  high  as  the  second  rib. 
In  tuberculosis  only  the  lower  end  of  the  sternum  is  thrown  for- 
wards, the  upper  part  of  the  chest  being  flattened  from  before  back- 
wards. 

'  See  an  article  on  Tuberculosis,  by  Sir  W.  Jenner,  Medical  Times  and  Gazette, 
July  6,  1861. 


190  CHRONIC    TUBERCULOSIS. 

This  tbird  variety  of  chest  may  be  found  in  a  healthy  child,  the 
lower  lobes  of  whose  lungs  have  become  diminished  in  size  through 
permanent  collapse  dependent  upon  repeated  attacks  of  bronchitis. 
It  is  not,  therefore,  distinctive  of  tuberculosis. 

The  symptoms  which  have  been  enumerated  continue  for  some 
time;  gradually  the  emaciation  increases;  the  cheeks  get  rather 
hollow,  the  eyes  sunken,  and  all  bony  projections  more  strongly 
marked.  The  skin  remains  thin  and  transparent,  or  becomes  dry, 
rough  and  yellowish.  The  child  gets  more  and  more  listless,  is 
dull  and  apathetic,  exerts  himself  unwillingly,  and  prefers  sitting 
or  lying  down  to  movement,  often  complaining  that  his  legs  ache. 
The  pulse  becomes  frequent,  but  generally  varies  in  rapidity  ac- 
cording to  the  degree  of  fever :  when  the  fever  is  high,  the  pulse 
is  quick ;  when  the  fever  subsides,  the  pulse  slackens.  It  is  always 
regular  in  rhythm.  This  relation  between  the  pulse  and  the  temper- 
ature is  not,  however,  always  preserved ;  the  pulse  may  be  rapid 
without  any  perceptible  increase  of  the  temperature  of  the  body. 
Usually  the  skin  gets  hotter  and  dryer  as  the  disease  goes  on,  the 
temperature  rising  at  night  to  102°  or  103°  Fahr.,  perspirations  oc- 
curring towards  morning.  Sudamina  in  older  children  may  be 
seen  on  the  chest ;  but  this  is  not  so  common  as  is  the  case  with 
adults.  The  appetite  is  preserved,  or  may  get  capricious ;  there  is 
some  thirst,  and  the  tongue  is  clean  and  reddish,  or  slightly  furred. 
The  bowels  are  often  irregular,  constipation  alternating  with  occa- 
sional attacks  of  diarrhoea,  when  the  motions  are  light  colored  and 
offensive.  The  sleep  at  these  times  may  be  disturbed,  the  child 
waking  with  a  start,  or  crying  in  great  terror. 

Ai'ter  a  time  the  breathing  becomes  more  rapid ;  there  may  be  a 
little  cough,  and  vague  pains  are  often  complained  of  about  the 
chest  and  belly.  The  emaciation  goes  on  slowly  as  long  as  the 
febrile  disturbance  remains  trifling;  but  when  this  becomes  more 
marked,  the  loss  of  flesh  is  rapid,  and  the  intensity  of  all  the  symp- 
toms is  increased.  Increased  rapidity  of  wasting  may  be  a  sign  of 
the  occurrence  of  some  inflammatory  complication. 

The  weakness  at  length  becomes  so  great  that  the  child  keeps 
his  bed,  and  can  hardly  be  persuaded  to  sit  up  even  to  take  food. 
The  appetite  fails  completely ;  aphthae  appear  upon  the  tongue, 
gums,  and  inside  of  the  cheeks  and  lips ;  the  lower  limbs  and  de- 
pending parts  of  the  body  are  swollen  from  the  presence  of  oedema, 
due  to  the  impoverished  state  of  the  blood,  independent  of  any  en- 


DIAGNOSIS.  191 

largement  of  the  mesenteric  glands;  and  death  maj  occur  without 
any  special  symptoms  having  arisen  to  suggest  disease  of  any  par- 
ticular organ.  More  usually,  however,  long  before  this  period 
some  local  symptoms  have  been  noted,  often  early  in  the  disease, 
and  it  occasionally  happens  that  these  local  symptoms  are  the  first 
signs  by  which  attention  is  attracted  to  the  state  of  the  child's 
health. 

Chronic  tuberculosis  seldom  runs  its  course  without  irregular 
attacks  of  acute  or  subacute  febrile  disturbance,  whether  from  in- 
creased formation  of  tubercle  or  from  inflammation.  The  tempera- 
ture almost  invariably  rises  towards  evening,  and  will  be  found  to 
be  over  100°  Fahr.  by  a  thermometer  placed  in  the  axilla. 

Diagnosis. — The  diagnosis  of  chronic  tuberculosis  before  any 
signs  have  appeared  to  denote  special  lesion  of  organs  is  exceed- 
ingly perplexing.  In  infants  the  difficulties  are  especially  great  at 
first,  although  usually  localization  of  the  disease  occurs  more  rea- 
dily in  them  than  in  older  children. 

Besides  actual  examination  of  the  infant,  very  valuable  infor- 
mation can  be  obtained  by  inquiries  into  his  previous  history,  the 
diseases  through  which  he  has  passed,  the  good  or  bad  hygienic 
conditions  under  which  he  has  been  reared,  and  the  health  of  his 
parents  and  family  generally.  Thus,  if  a  child  has  been  brought 
up  injudiciously,  and  has  escaped  rickets;  if  the  parents  or  other 
members  of  the  family  are  the  subjects  of  tubercle ;  or  if  the 
child  has  lately  suffered  from  measles  or  whooping-cough,  and  has 
never  completely  recovered,  we  should  suspect  tuberculosis.  But 
even  with  this  assistance  it  is  not  easy  to  arrive  at  a  satisfactory 
conclusion,  at  any  rate  at  once.  Simple  wasting  from  insufficient 
nourishment  may  very  closely  simulate  tuberculosis ;  and  a  rickety 
child  may  have  tubercle  developed  as  a  secondary  condition.  In 
these  cases  the  results  of  treatment  afford  a  very  important  means 
of  estimating  the  nature  of  the  disease.  Thus,  if  the  diet  and  hy- 
gienic arrangements  are  altered,  and  the  child  instantly  begins  to 
improve,  the  absence  of  tubercle  becomes  exceedingly  probable. 
If,  however,  a  different  result  follows  such  alteration,  and  the  con- 
dition of  the  child  remains  unchanged,  it  does  not  necessarily 
follow  that  tubercle  is  present,  for  chronic  diarrhoea  may  persist 
and  may  cause  death,  not  only  without  tubercle  existing,  but  even 
without  the  existence  of  any  lesions  sufficiently  serious  to  account 
for  the  fatal  termination.     Under  such  circumstances  the  thermo- 


192  CHRONIC    TUBERCULOSIS. 

meter  becomes  an  important  aid  to  diagnosis.  None  of  these 
diseases  are  accompanied  bj  a  persistent  increase  of  temperature, 
although  a  very  slight  cause  is  sufficient  to  produce  a  temporary 
increase  in  the  heat  of  the  body.  If,  then,  we  find  persistent  ele- 
vation of  temperature  at  night,  estimated  by  the  thermometer  in 
the  axilla,  and  that  this  elevation  continues  for  several  days  or 
weeks  in  succession,  without  any  discoverable  cause  to  account  for 
the  rise,  we  may  safely  diagnose  tuberculosis.^  Unless,  then,  we 
can  obtain  some  positive  evidence,  such  as  that  aftbrded  by  the 
thermometer,  it  is  better  in  the  case  of  an  infant  to  reserve  a  de- 
cision, until  some  more  decided  symptoms  are  manifested  ;  and 
these  are  seldom  long  postponed.  Localization  of  the  disease  soon 
draws  attention  to  some  especial  organ,  usually  the  lungs  or  the 
bronchial  glands. 

In  the  case  of  older  children  the  diagnosis  rests  upon  steady 
emaciation,  accompanied  by  more  or  less  irregular  febrile  disturb- 
ance, without  any  serious  local  lesion  to  account  for  the  symptoms. 
Under  such  circumstances  worms  are  often  suspected,  and  purga- 
tive after  purgative  is  given  to  clear  out  the  supposed  parasites 
from  the  bowels.  As  has  been  already  stated,  however,  all  the 
symptoms  usually  attributed  to  worms  may  be  present,  although 
repeated  aperients  fail  to  produce  any  evidence  of  their  existence. 
A  condition  of  the  alimentary  canal  is  frequently  noticed  in 
children  which  consists  in  abundant  secretion  of  intestinal  mucus, 
causing  fermentation  of  food,  and  great  impediment  to  digestion 
and  assimilation.  This  does  not  necessarily  lead  to  the  formation 
of  tubercle,  although  it  is  sometimes  followed  by  ill-defined  spots 
of  dulness  about  the  lungs,  and  by  glandular  enlargements.  These 
phenomena  would  perhaps  be  more  correctly  ascribed  to  scrofulous 
changes  than  to  true  tubercle,  and  they  are  besides  by  no  means 
a  necessary  result  of  the  derangement.  One  essential  difference 
between  this  disease  and  tuberculosis  is  seen  in  the  fact,  that  by 
proper  measures  the  former  can  be  readily  cured,  and  the  result  of 
treatment  becomes,  therefore,  a  test  of  the  nature  of  the  disorder. 
(See  Mucous  Disease.) 

In  the  diagnosis  of  tuberculosis  it  is  important  not  to  be  misled 
by  the  condition  of  the  stomach  and  bowels.     It  often  happens 

'  On  the  Temperature  of  the  Body  as  a  Means  of  Diagnosis  in  Phthisis  and 
Tuberculosis,  by  Sydney  Ringer,  M.  D.     London,  1865. 


CAUSES.  193 

that  there  is,  in  addition  to  slight  febrile  disturbance,  a  little  diar- 
rhoea, with  unhealthy-looking  offensive  motions,  and  loss  of  appetite. 
The  attention  is  apt,  therefore,  to  be  directed  entirely  to  these 
obvious  points  to  the  exclusion  of  the  more  serious  affection  of 
which  they  are  merely  accompaniments.  In  such  cases  a  diagnosis 
can  usually  be  made  by  inquiring  whether  the  general  symptoms 
preceded  or  followed  the  intestinal  derangement.  The  influence 
of  rem.edies  is  also  an  important  guide.  In  the  case  of  tubercu- 
losis, the  general  symptoms  continue  after  the  condition  of  the 
bowels  has  become  improved. 

Causes. — Tuberculosis  is  a  diathetic  disease ;  in  other  words,  it 
is  the  result  of  a  constitutional  tendency,  more  or  less  pronounced, 
to  this  particular  form  of  pathological  lesion.  Of  the  children 
who  are  born  with  this  constitutional  predisposition  a  large  number 
come  of  tubercular  parents,  or  of  families  in  which  some  members 
suffer,  or  have  suffered,  from  the  disease.  It  does  not,  however, 
follow  that  tubercular  parents  must  necessarily  have  tubercular 
children.  Such  children  may  grow  up  without  evincing  any  ten- 
dency to  the  disease,  the  predisposition  either  not  having  been 
manifested  in  them,  or  if  present,  having  been  effaced  by  the  care 
and  attention  to  hygienic  rules  with  which  the  children  have  been 
reared.  The  tendency,  whether  hereditary  or  not,  may  be  of 
itself  sufficiently  powerful  to  give  rise  to  the  disease  without  the 
influence  of  any  external  causes  to  which  such  development  can 
be  attributed :  or  it  may  remain  latent  until  roused  by  circum- 
stances to  assert  itself,  and  to  produce  its  natural  consequences. 
Of  the  children  who  become  the  subjects  of  this  disease  a  certain 
proportion  are  descended  from  parents  in  whom  no  similar  tend- 
ency is  manifested,  in  families  altogether  free  from  the  tuberculous 
taint.  It  seems  probable,  therefore,  that  the  tuberculous  diathesis 
can  be  acquired  by  children  whose  constitution  is  at  birth  entirely 
free  from  any  such  predisposition. 

The  exciting  causes  which  may  determine  the  development  of 
this  diathetic  state  consist  of  anything  which  interferes  with  the 
nutrition  of  the  body,  whether  by  preventing  the  introduction  of 
nutriment  into  the  system,  or  by  obstructing  the  escape  of  waste 
matter  whose  removal  is  indispensable  to  the  proper  working  of 
the  different  functions.  In  thia  respect  it  resembles  syphilis  and 
scrofulosis,  the  two  other  diathetic  diseases  of  children.  In  them, 
too,  the  constitutional  tendency,  as  yet  latent,  may  be  awakened 
13 


194  CHKONIC    TUBERCULOSIS, 

by  any  cause  ■which  interferes  temporarily  with  nutrition,  and 
therefore  "hinders  or  disturbs  the  normal  maintenance  and  devel- 
opment of  the  organism."^  Such  causes  are  impure  air,  insufficient 
or  improper  food,  cold  and  damp,  want  of  sunlight  and  of  exercise; 
a  combination  of  these  will  in  any  case  awaken  the  dormant  tend- 
ency and  excite  its  manifestations. 

Certain  diseases  may  also  be  the  starting-point  for  the  develop- 
ment of  tubercle  in  subjects  predisposed  to  the  disease.  Of  these 
pneumonia  may  excite  the  formation  of  tubercle  in  the  lung.  No 
doubt  many  of  the  cases  described  as  tubercle  occurring  as  a  result 
of  pulmonary  inflammation  have  been  merely  cases  of  scrofulous 
pneumonia,  the  so-called  tubercle  being  the  yellow  infiltrated  de- 
posit which  is  the  result  of  that  special  form  of  the  disease ;  but 
this  pneumonic  consolidation  may  itself  be  the  exciting  cause  of 
the  formation  of  true  gray  tubercle  in  the  tissue  around  it.  (See 
Pulmonary  Phthisis.) 

Measles  and  whooping-cough  are  also  often  the  cause  of  the 
tubercular  manifestation,  but  seldom,  according  to  MM.  Killiet  and 
Barthez,  except  in  conjunction  with  the  other  exciting  causes 
which  have  been  mentioned.  In  these  cases  it  is  especially  the 
lungs  and  the  bronchial  glands  which  suffer  from  the  presence  of 
tubercle.^ 

1  Niemeyer's  Lectures  on  Phthisis.     New  Sydenham  Society. 

2  The  question  of  the  iuoculability  of  tubercle  has  lately  been  the  subject  of 
investigation.  The  first  experiments  were  made  by  M.  Villemin,  who  laid  the 
results  of  his  inquiries  before  the  French  Academy  in  1865.  The  investigations 
have  been  continued  in  England  by  Drs.  Andrew  Clark,  Wilson  Fox,  Sanderson, 
and  by  Mr.  Simon.  From  their  experiments  it  appears  that  in  the  guinea-pig,  or 
rabbit,  the  careful  introduction  of  tuberculous  matter  under  the  skin  is  followed 
by  the  formation  of  a  pathological  product,  which  differs  in  no  appreciable  respect, 
according  to  Dr.  Fox,^  from  ordinary  gray  tubercle,  as  that  occurs  in  the  human 
subject,  either  by  its  naked-eye  or  microscopic  characters,  by  its  mode  of  distribu- 
tion, the  organs  affected,  or  even  the  parts  of  the  organs  affected.  Dr.  Andrew 
Clark  pointed  out  that,  not  only  tubercle,  but  other  matters  non-tubercular  would 
produce  the  same  result ;  and  Dr.  Sanderson  showed  that  even  the  local  irritation 
excited  by  the  introduction  of  a  seton,  was  as  capable,  under  certain  circumstances, 
of  producing  tubercle  as  any  of  the  animal  substances  which  had  previously  been 
experimented  with. 

With  respect  to  the  identity  or  non-identity  with  true  gray  granulations  of  the 


3  See  Lecture  by  Dr.  Wilson  Fox  on  the  Artificial  Production  of  Tubercle  in  the 
Lower  Animals,  delivered  at  the  Royal  College  of  Physicians,  May  15th,  18(38. 
Published  in  the  Lancet  for  May  23-30,  18G8. 


PREVENTION.  195 

Prevention. — If  the  mother  is  consumptive,  she  should  on  no 
account  be  allowed  to  suckle  her  child  longer  than  the  end  of  the 
first  month  ;  a  healthy  wet  nurse  should  then  be  provided  to  take 
her  place.  So  much  has  been  said  in  the  present  volume  as  to  the 
feeding  and  general  management  of  young  children,  that  it  will 
not  be  necessary  to  repeat  in  this  place  the  different  rules  for  the 
diet,  clothing,  etc.,  of  infants,  which  have  been  already  laid  down. 
The  reader  is  referred  to  the  section  containing  the  treatment  of 
simple  atrophy,  and  that  on  the  prevention  of  diarrhoea,  for  full 
information  upon  these  points. 

The  diet  of  an  older  child  should  also  be  so  arranged  that  he 
may  take  as  much  as  he  can  readily  digest,  but  no  more.  Animal 
food  should  be  given  to  him  only  once  in  the  day,  and  should  be 
either  roasted  or  boiled :  meat  cooked  a  second  time,  as  hashes,  or 
stews,  or  meat  fried  in  grease,  are  less  digestible,  and  should  not 
be  allowed.  After  the  age  of  two  years  a  child  should  take  four 
meals  a  day:  of  these,  two  should  consist  of  bread  and  milk;  a 
third  of  meat,  finely  minced  at  the  first,  afterwards  cut  into  small 
pieces,  with  a  little  potato  carefully  mashed,  and  gravy  ;  a  fourth 
of  farinaceous  pudding,  or  an  egg  lightly  boiled.  The  milk  should, 
if  possible,  be  fresh  from  the  cow  ;  if  not,  a  tablespoonf ul  of  cream 
should  be  added.  It  is  important  to  accustom  the  child  early  to 
masticate  his  food  thoroughly:  this  point  should  be  always 
attended  to.  Children  often  wake  hungry  in  the  early  morning : 
it  is  Avell  in  such  cases  to  place,  overnight,  a  piece  of  dry  stale 
bread,  or  a  plain  biscuit,  by  the  side  of  their  bed,  so  that  they  may 
not  be  forced  to  wait  without  food  until  their  breakfast  is  prepared. 

Well  ventilated  rooms,  fresh  air,  and  plenty  of  exercise  have 
already  been  insisted  upon.     The  skin  should  be  kept  perfectly 

pathological  appearances  produced  by  inoculatiou,  the  experimenters  differ.  Dr. 
Wilson  Fox  advocates  the  view  of  the  true  tuberculous  nature  of  these  formations, 
grounding  his  opinion  upon  the  fact  that  in  the  lung  the  point  of  departure  is  in 
DO  respect  from  the  vascular  appa^ratus,  the  new  structure  not  being  an  infiltration 
of  the  alveoli,  but  a  thickening  of  the  wall  of  the  air-cell  which  finally  closes  the 
vesicle.  The  air-cell,  he  states,  is  the  last  thing  to  be  occluded,  and,  "  even  in  the 
densest  masses,  examined  with  a  binocular,  a  certain  transparency  can  still  be 
seen,  distinctly  in  some  places,  showing  that  the  central  portions  of  the  alveoli 
are  still  hollow."  Dr.  Clark,  however,  maintains  that  these  products,  whatever 
they  may  really  be,  are  at  any  rate  not  tubercular  ;  for  although  anatomically 
they  may  resemble  tubercles,  clinically  they  difi'er  from  them  in  almost  every 
particular.  He  believes  that  in  determining  the  nature  of  a  pathological  product, 
its  clinical  history  is  of  infinitely  greater  value  than  its  anatomical  condition. 


196  CHRONIC    TUBERCULOSIS. 

clean  by  cold  or  tepid  sponging  over  the  whole  body  in  a  bath, 
twice  a  day,  and  should  be  afterwards  excited  gently  to  act  by 
friction  with  the  hand,  as  has  been  previously  recommended. 

The  dress  should  be  warm,  but  loose :  tight  waist-bands,  and,  in 
girls  stays  are  exceedingly  injurious.  Nothing  should  be  allowed 
to  interfere  with  the  free  play  of  the  chest.  Pressure  upon  the 
ribs  not  only  prevents  a  proper  expansion  of  the  lungs,  but  also 
is  apt  to  cause  displacement  of  the  liver  and  stomach,  and  much 
derangement  of  the  functions  of  digestion  and  respiration  may  be 
the  consequence.  "The  only  way,"  says  Dr.  Underwood,^  "in 
which  we  can  assist  in  forming  a  really  fine  figure,  is,  to  remove 
all  restraint,  and  secure,  as  far  as  possible,  so  free  an  action  to  the 
muscles  as  will  lead  to  their  perfect  development.  By  such  a 
course  we  shall  best  promote  the  acquirement  of  a  good  carriage, 
which  is  infinitely  more  likely  to  be  the  result  of  a  perfect  balance 
of  the  muscles,  than  of  any  mechanical  support  whatever." 

The  preceding  remarks  do  not  refer  to  the  abdominal  belt, 
which  should  always  be  worn  until  the  child  is,  at  any  rate,  three 
years  old.  The  band  covers  the  belly,  but  does  not  confine  the 
ribs,  if  properly  applied  round  the  upper  part  of  the  pelvis. 

Children,  both  boys  and  girls,  should  be  encouraged  to  exercise 
their  muscles  by  out-door  games,  and  by  gymnastic  exercises  suited 
to  their  age  and  sex.  While,  however,  plenty  of  fresh  air  and 
exercise  out  of  doors  are  of  such  extreme  importance,  yet  un- 
necessary exposure  of  children  to  cold  winds  and  damp  air,  with 
a  view  of  "hardening  the  system,"  is  a  practice  which  cannot  be 
too  strongly  condemned.  The  most  robust  children  are  exceed- 
ingly sensitive  to  changes  of  temperature,  and  in  cold  damp  air 
readily  part  with  their  heat,  and  become  pinched  and  blue,  show- 
ing that  they  are  sufi'ering  from  the  efiects  of  cold.  Many  an 
attack  of  inflammation  of  the  lungs  has  been  excited  by  such  a 
practice,  and  in  children  already  predisposed  to  tuberculosis 
unnecessary  exposure  is  one  of  the  most  certain  ways  of  encourag- 
ing the  tendency.  A  dry,  airy  situation  should  be  always  recom- 
mended. Dr.  Buchanan^  has  shown  that  phthisis  is  much  more 
prevalent  amongst  populations  liviugon  low-lying  impervious  soils, 
than  amongst  the  residents  of  places  more  highly  situated,  and 

'  Diseases  of  Children,  edited  by  Henry  Pavies,  M.  D.     London,  1846. 
2  Tenth  Report  of  the  Medical  Officers  of  the  Privy  Council.      1868. 


TREATMENT.  197 

wliere  the  soil  is  pervious.  In  the  selection  of  a  house  this  is  a 
matter,  therefore,  of  considerable  importance. 

In  children  suffering  from  caries  of  bones,  an  early  removal  of 
the  whole  of  the  diseased  bone  is  strongly  advocated  by  Mr,  Holmes. 
Tubercuarl  disease  of  the  lungs  and  internal  organs  is  a  frequent 
accompaniment  of  such  a  condition,  and  appears  to  be  rather  the 
effect  than  the  cause  of  the  bone  disease.  The  complete  removal 
of  diseased  bone  may,  therefore,  prevent  the  occurrence  of  tuber- 
cular disease  in  children  where  a  predisposition  exists.  The  opera- 
tion should  be  performed  early.  The  child  then  usually  quickly 
recovers,  and  often  becomes  strong  and  healthy.^ 

Treatment. — In  the  treatment  of  tuberculosis  three  things  are 
indispensable.  A  free  supply  of  fresh  air,  avoiding  chills;  a 
moderate  amount  of  exercise,  avoiding  over-fatigue ;  and  plenty 
of  nourishing  food,  avoiding  repletion  and  indigestion.  The  child 
should  pass  as  much  time  as  possible  out  of  doors  during  the  day, 
returning,  however,  to  the  house  before  sunset,  as  the  temperature 
often  falls  considerably  at  that  time,  and  rapid  changes  of  tem- 
perature are  to  be  avoided.  Cold  is  not  so  injurious  as  damp. 
These  patients,  if  warmly  clothed,  often  bear  well,  and  are  benefited 
by  cold  air ;  damp,  however — at  any  rate  the  moist  air  of  low- 
lying  inland  situations — is  extremely  prejudicial,  and  while  the 
ground  is  wet  the  children  should  be  kept  in-doors,  or  should  only 
be  exercised  with  very  great  caution.  The  moist  air  of  the  sea- 
side does  not  appear  to  be  so  injurious,  and  many  cases  of  tuber- 
culosis are  greatly  benefited  by  a  residence  near  the  sea.  For  the 
winter  months,  and  in  cases  where  a  change  of  air  is  advisable,  it 
often  becomes  a  question  of  considerable  difliculty  to  decide  upon 
the  best  climate  to  which  the  patient  can  be  sent.  It  may  be  laid 
down  as  a  rule  that  the  best  climate  for  a  patient  suffering  from 
tuberculosis  is  one  where  the  temperature  is  as  low  as  can  be 
borne.  A  warm  climate,  unless  in  exceptional  cases,  is  of  no 
special  advantage,  and  heat  combined  with  moisture,  as  in  Ceylon 
and  Madeira,  is,  as  a  rule,  positively  injurious.  A  hot,  moist 
climate  is  only  of  value  in  cases  where  there  is  excessive  irrita- 
bility of  the  bronchial  mucous  membrane,  a  condition  which  would 
be  increased  by  warm  dry  air.  In  the  earlier  stages  of  tubercu- 
losis this  is,  however,  seldom  a  prominent  symptom.     The  object 

I  See  Lancet,  vol.  ii.,  1864,  p.  236  ;  vol.  i.,^1865,  p.  59. 


198  CHRONIC    TUBERCULOSIS. 

of  a  change  of  residence  in  this  disease  is  to  obtain  a  climate 
where  the  patient  can  pass  his  time  out  of  doors  without  incurring 
the  risk  of  catarrh,  and  where  at  the  same  time,  the  quality  of  the 
air  is  sufficiently  invigorating.  When  the  climate  is  damp  as  well 
as  warm,  the  relaxing  qualities  imparted  by  the  moisture  usually 
cause  so  much  depression,  destroying  the  appetite  and  increasing 
the  languor,  as  to  counteract  the  benefit  afforded  by  the  more 
genial  air.  In  determining  this  question  regard  should  always  be 
paid  to  individual  peculiarities.  Some  children  will  require  a 
much  greater  degree  of  warmth  than  others,  and  it  will  be  neces- 
sary to  take  into  consideration  the  influence  which  differences  in 
temperature  have  already  appeared  to  exercise  upon  the  health  of 
the  patient — whether  he  has  seemed  to  be  more  benefited  by  heat 
or  by  cold — before  deciding  in  any  case  upon  the  exact  climate 
which  offers  the  best  chance  of  recovery.  For  the  special  advan- 
tages afforded  by  different  localities  the  reader  is  referred  to  the 
many  excellent  works  upon  this  subject  which  have  been  published, 
and  some  admirable  remarks  upon  the  choice  of  a  climate  in  the 
treatment  of  pulmonary  consumption  will  be  found  in  Dr.  Fuller's 
work  on  the  diseases  of  the  lungs.^  It  may  be  remarked,  however, 
that  dryness  of  soil  and  protection  from  north  and  east  winds 
during  the  winter  and  early  spring,  are  essential  in  every  case. 
The  other  conditions  to  be  desired  must  be  determined  by  the 
requirements  of  the  particular  case. 

Moderate  exercise  while  out  of  doors  should  always  be  enjoined, 
due  regard  being  had  to  the  degree  of  vigor  of  the  patient.  This 
is  exceedingly  important,  as,  unless  the  weather  be  warm,  a  proper 
action  of  the  muscles  is  required  to  stimulate  the  circulation  and 
prevent  the  body  being  affected  by  the  cold.  Over-fatigue  must, 
however,  be  carefully  avoided,  and  if  there  is  any  feeling  of  cold 
after  a  short  stay  in  the  open  air,  it  will  be  necessary  to  return  at 
once  to  the  house.  If  the  child  is  strong  enough,  pony  or  donkey 
exercise  should  be  recommended.  In  cases,  however,  where  the 
exertion  required  for  riding  is  too  severe,  an  open  carriage  can  be 
substituted,  and  the  child  can  occasionally  take  a  short  walk,  re- 
turning to  the  carriage  when  fatigued.  Care  must  be  taken  that 
the  child  is  perfectly  warm  before  he  leaves  the  house.     If  he  is 

'  Diseases  of  the  Lungs  and  Air-Passages,  by  H.  W.  Fuller,  M.D.,  Cantab.,  2d 
ed.,  1867. 


DIET.  199 

chilly  wben  starting  upon  his  airing,  his  power  of  resisting  external 
cold  is  very  much  impaired.  Different  exercises  should  be  devised 
by  means  of  which  the  muscles  of  the  arms,  chest,  and  back  may 
be  brought  into  action.  The  use  of  dumb-bells,  and  of  the  elastic 
instrument  known  as  the  "  chest-expander,"  is  very  serviceable  in 
these  cases ;  by  such  means  the  capacity  of  the  chest,  may  be  very 
much  increased,  and  greater  freedom  be  given  to  the  play  of  the 
lungs.  Where  the  strength  permits,  all  out-door  games  should  be 
encouraged,  care  being  taken  to  stop  short  of  actual  fatigue. 
Shampooing  must  not  be  forgotten ;  by  this  means  the  develop- 
ment of  the  muscles  is  aided,  and  the  action  of  the  skin  is  pro- 
moted.    It  should  be  practised  every  morning  after  the  bath. 

In  doors,  free  ventilation  must  be  sustained,  while  every  care  is 
taken  to  avoid  draughts.  In  winter,  it  is  important  that  the  rooms 
should  be  kept  at  an  even  temperature,  and  that  the  passages 
should,  if  possible,  be  warmed.  If  this  is  impracticable,  some 
extra  clothing  should  be  put  on  in  passing  from  one  room  to  the 
other. 

The  action  of  the  skin  must  be  promoted  by  warm  clothing,  and 
by  daily  sponging  with  tepid  water.  In  the  early  stages  of  the 
disease  the  cold  bath,  at  a  temperature  of  60°  Fahr.,  may  be  em- 
ployed if  its  use  is  found  to  be  followed  by  a  proper  reaction ;  if 
not,  and  the  child  remains  languid  and  chilly,  the  temperature  of 
the  water  must  be  raised.  Tuberculous  children  should  always 
wear  a  shirt  and  drawers  of  flannel  next  to  the  skin. 

The  diet  of  the  child  should  be  arranged  as  described  under  the 
head  of  prevention;  four  small  meals  being  preferable  to  three 
larger  ones  in  the  day.  Plenty  of  new  milk  is  essential,  and  should 
always  be  given  undiluted  if  it  can  be  borne.  Sometimes,  how- 
ever, in  these  cases  there  is  a  tendency  to  acidity  of  the  stomach. 
This  can  be  corrected  by  the  addition  of  lime-water,  or  of  fifteen 
or  twenty  drops  of  the  saccharated  solution  of  lime  to  the  milk. 
On  account  of  the  debility  of  the  digestive  organs,  which  is  so 
common  in  this  disease,  it  is  necessary  to  exercise  great  care  in 
the  selection  of  the  diet.  The  simplest  articles  of  food  are  the 
best,  as  plain  roast  beef  or  mutton,  with  gravy,  mealy  potatoes 
well  mashed,  milk,  and  strong  beef  or  mutton  tea,  free  from  grease. 
Clear  turtle  soup  is  exceedingly  digestible  and  nutritious.  If  eggs 
are  allowed  they  should  be  lightly  boiled  or  poached,  or  they  may 
be  beaten  up  with  warm  milk.     Farinaceous  food  should  enter  into 


200  CHRONIC    TUBERCULOSIS. 

the  diet,  but,  on  account  of  its  tendency  to  undergo  fermentation 
and  produce  acid,  its  effects  must  be  carefully  watched,  and  no 
more  should  be  given  than  can  with  safety  be  digested.  Often, 
however,  the  appetite  is  very  capricious,  and  there  is  a  disgust  for 
meat,  and  for  the  plainer  articles  of  food,  which  it  is  very  difficult 
to  overcome.  In  such  cases,  frequent  changes  should  be  made  in 
the  diet,  tempting  the  appetite  with  a  small  bird,  as  a  quail  or  a 
snipe,  with  fish,  as  turbot,  cod,  or  boiled  sole,  or  with  raw  oysters. 
The  addition  of  alcohol  is  often  useful  in  stimulating  the  appetite  : 
weak  claret  and  water,  or  a  large  wineglassful  of  light  bitter  ale, 
may  be  given  to  a  child  of  six  or  seven  years  old,  with  one  of  his 
meals.  The  occasional  administration  of  two  or  three  grains  of 
hydrargyrum  cum  creta  with  a  little  powdered  rhubarb  will  often 
improve  the  appetite  when  that  is  failing,  and  dilute  nitric  acid  in 
a  bitter  infusion,  as  infus,  calumb^,  or  a  drop  or  two  of  dilute 
hydrocyanic  acid,  with  ten  grains  of  carbonate  of  potash,  and 
half  a  grain  of  iodide  of  potassium,  may  be  given  three  times  a 
day  in  the  same  vehicle.^  A  most  marked  improvement  in  this 
respect  is  often  effected  by  a  change  of  residence  to  a  dry  bracing 
air,  and  where  the  patient  is  living  in  a  relaxing  situation,  this 
change  should  always  be  made  if  possible. 

A  careful  watch  must  be  kept  over  the  condition  of  the  bowels, 
for  our  hopes  of  improving  the  nutrition  of  the  body  depend 
entirely  upon  the  accuracy  of  the  performance  of  the  digestive 
functions.  Violent  purgatives  should  be  avoided  ;  if  there  is  con- 
stipation, an  occasional  dose  of  castor  oil,  or  of  decoction  of  aloes, 
will  be  sufficient  to  produce  an  evacuation.  The  most  common 
condition  is  one  in  which  the  bowels  are  relaxed,  three  or  four 
light-colored  offensive  motions  being  passed  in  the  course  of  the 
day.  In  these  cases  opium  is  a  most  valuable  medicine,  and  should 
be  given  with  dilute  sulphuric  acid,  if  the  tongue  is  clean,  as  in 
the  following  mixture : — 

^..  Tinct.  opii,  "n^xxiv  ; 

Acidi  sulphuric!  aromat.,  gj  ; 

Tinct.  myrrhse,  gjss ; 

Syrupi  aurantii,  ^j  ; 

Infusi  aurantii  ad  §vj.     M.     ^ss  ter  die. 

or,  if  there  is  much  straining,  with  mucus  in  the  stools,  and  a 
furred  tongue,  it  can  be  given  with  castor  oil: — 

'  AH  the  prescriptions  in  this  section  are  suitable  to  a  child  of  five  years  old. 


ALKALIES.  201 

^,  Tiuct.  opii,  iT^xxiv  ; 
Olei  ricini,  5iij  ; 
Syrnpi, 

Mucilaginis  acaciae,  aa  §j  ; 
Aq.  menth.  pip.,  ad  §vj.     M.  §33  ter  die. 

The  flannel  bandage  should  always  be  worn  ro  und  the  belly  in 
these  cases.  The  addition  of  a  drop  of  tincture  of  capsicum  to 
each  dose  of  either  of  the  preceding  mixtures  often  renders  them 
more  efficacious.  Capsicum  is  extremely  useful  in  all  cases  of 
non-inflammatory  diarrhoea  in  children,  as  it  seems  to  exercise  a 
powerful  stimulating  effect  upon  the  internal  surface  of  the  ali- 
mentary canal.  If  the  stools  remain  light-colored  after  the  mo- 
tions have  become  more  solid,  a  small  dose  of  rhubarb  with  gray 
powder  may  be  given  to  increase  the  secretion  of  bile. 

Alkalies  have  been  very  strongly  recommended  by  many 
authors,  and — whether  it  is  that  they  influence  the  oxidation  of 
tuberculous  matter,  as  suggested  by  some,  or  that  their  effect  is 
merely  upon  the  digestive  organs,  neutralizing  any  excess  of 
acidity  in  the  canal — there  is  no  doubt  that  their  use  is  often 
followed  by  considerable  benefit.  One  of  the  best  forms  in  which 
an  alkali  can  be  given  is  the  mixture  containing  potas.  bicarb., 
potas.  iod.,  and  dilute  hydrocyanic  acid,  given  above.  Dr.  Greorge 
Buchanan  recommends  the  citrate  of  potash,  and  states  that  he  has 
often  seen  the  most  satisfactory  results  follow  the  use  of  this  drug, 
"  not  at  a  distance  of  time,  but  in  the  course  of  three  or  four 
weeks'  treatment."^  Small  doses  of  liq.  potassse  with  nitrate  of 
potash  may  be  given  if  there  is  any  irritability  of  the  stomach. 
When  the  digestive  organs  have  been  brought  into  a  healthy  state, 
cod-liver  oil  and  tonics  become  necessary  to  continue  the  improve- 
ment, and  are  as  beneficial  at  this  stage  of  the  disease  as  they 
would  be  injurious  so  long  as  there  remains  any  functional  de- 
rangement of  the  alimentary  canal.  Cod-liver  oil  is  of  immense 
service,  but  care  must  be  taken  to  proportion  the  dose  to  the 
digestive  power  of  the  patient,  for  children  vary  greatly  in  their 
power  of  digesting  fats.  If  more  is  given  than  can  be  digested, 
the  residue  passes  unaltered  through  the  bowels,  and  is  apt  to  excite 
diarrhoea.  At  first,  half  a  teaspoonful  is  a  sufficient  dose :  it 
should  be  taken  three  times  a  day,  after  meals,  in  a  little  milk, 

'  Lftttsomian  Lectures  on  the  Diagnosis  and  Management  of  Lung  Diseases  iu 
CLildieu,  Lancet,  Feb.  1,  1868. 


202  CHRONIC    TUBERCULOSIS, 

orange  wine  and  water,  or,  better  still,  in  a  cold  infusion  of  orange- 
peel.  The  dose  can  be  afterwards  increased,  but  the  stools  should 
be  always  examined  from  time  to  time  for  undigested  oil.  More 
than  two  teaspoonfuls  three  times  a  day  can  seldom  be  borne,  and 
less  than  that  quantity  will  often  be  found  sufficient.  When  the 
oil  is  given  with  care,  and  not  too  early,  it  seldom  disagrees. 
Should  any  temporary  digestive  disturbance  arise,  the  oil  must  be 
omitted  until  this  has  subsided,  after  which  it  may  be  recommenced, 
but  at  first  in  smaller  doses.  In  cases  Avhere  the  oil  cannot  by  any 
means  be  made  to  agree,  it  may  be  administered  by  inunction  into 
the  skin.  When,  however,  the  stomach  is  delicate,  the  constant 
smell  of  the  oil  often  excites  so  much  nausea  and  discomfort,  that 
the  plan  can  seldom  be  continued  for  long  together. 

Sugar  is  strongly  recommended  by  Dr.  Fuller  as  a  substitute  for 
cod-liver  oil,  and  may  be  taken  by  children  in  the  agreeable  form 
of  sugar  candy  or  barley  sugar,  after  meals.  If,  however,  it  de- 
ranges the  stomach  and  causes  acidity,  its  use  must  be  abandoned. 

Under  the  head  of  tonics,  iron  takes  the  first  place.  It  may  be 
given  as  vinura  ferri ;  liquor  ferri  pernitratis  with  dilute  nitric 
acid ;  the  ammonia-citrate  ;  the  potassio-tartrate ;  reduced  iron  (in 
doses  of  half  a  grain  twice  a  day,)  or  the  syrups  of  the  phosphate 
or  iodide.  If  the  syrup  be  objected  to,  the  iodide  may  be  conve- 
niently given  as  in  the  following  mixture : — 

^..  Ferri  et  potassae-tartratis,  3j  ; 
Potas.  iodidi,  9j  ; 
Aquse  destillatae,  §vj,     M,     §S3  ter  die. 

Iron  has  been  objected  to,  as  tending  to  produce  irritation  and 
congestion  of  the  lungs  and  haemoptysis.  If,  however,  it  is  not 
given  in  too  large  doses,  such  effects  in  children  are  seldom  seen  to 
follow  its  employment.  On  the  contrary,  where  the  condition  of 
the  stomach  and  bowels  is  satisfactory,  its  use  is  generally  followed 
with  very  great,  if  only  temporary,  advantage. 

Besides  iron,  other  tonics  may  be  given  ;  as  quinine,  which  may 
be  usefully  combined  with  iron,  as  in  the  double  citrate  of  iron 
and  quinine  (dose  five  grains  ter  die,  dissolved  in  glycerine);  de- 
coction of  cinchona;  tannic  acid,  either  in  a  mixture  with  dilute 
nitric  acid  or  as  the  decoction  of  oak-bark  ;  and  the  tincture  of  nux 
vomica.  All  these  may  be  tried,  and  sometimes  one,  sometimes 
another,  will  appear  to  be  beneficial. 


CHAPTER     IX. 

CHRONIC    PULMONARY   PHTHISIS. 

Chronic  Pulmonary  Phthisis  comprehends  several  distinct  pathological  processes 
— Infrequeucy  of  extensive  pulmonary  disintegration  in  young  children — 
Symptoms — Physical  signs — Their  value — Anatomical  characters — Gray  and 
yellow  tubercle— Scrofulous  or  epithelial  pneumonia— Softening  of  consoli- 
dating material — Cavities — Fibroid  phthisis. 

Diagnosis. — Of  tubercle— Of  scrofulous  pneumonia— Its  complication  with  gray 
tubercle — Of  fibroid  phthisis — Diagnosis  of  cavities — From  effusion  into 
pleura — From  diluted  bronchi. 

Prognosis. —  Causes. 

Treatment. — General — Special — Use  of  expectorants — Alkalies — Treatment  of  uu- 
absorbed  pneumonic  deposits — Counter-irritation. 

Under  the  head  "Phthisis"  are  included  many  morbid  condi- 
tions. The  term  includes  not  only  those  pathological  changes  due 
to  the  presence  in  the  tissues  of  gray  or  yellow  miliary  tubercle, 
but  also  those  extensive  structural  alterations  which  appear  to  be- 
long more  especially  to  the  scrofulous  habit  of  body — alterations 
which  were  once,  and  by  many  pathologists  still  are,  attributed  to 
tubercle,  but  which  by  others  are  considered  to  arise  independently 
of  it,  and  to  be  the  result  of  distinct  pathological  processes. 

Whether  the  term  tubercle  should  bear  the  extensive  application 
given  to  it  by  Bayle,^  Laennec,  and  the  French  pathologists  gene- 
rally, or  should  be  used  only  in  the  restricted  sense  in  which  Vir- 
chow  and  many  modern  observers  are  disposed  to  employ  it,  is  a 
question  important  enough  in  a  scientific  point  of  view,  but  of  com- 
paratively little  moment  to  the  practical  physician.  For  him  it  is 
sufl&cient  to  ascertain  the  existence  of  a  morbid  material  tending 
to  soften,  break  down,  and  excite  ulcerative  action  in  the  tissues 
around  it. 

In  the  present  chapter  it  is  intended  to  treat  the  subject  clini- 
cally; to  describe  the  disease  phthisis  as  it  appears  to  us  at  the 

'  See  issue  for  1803  and  1805  of  the  Journal  de  Medecine  of  Corvisart,  t.  vi.  ix.  x. 


20-i  CHRONIC    PULMONARY    PHTHISIS. 

bedside ;  to  deal  with  the  condition  "  wasting"  as  one  caused  by 
certain  chronic  changes  in  the  lungs,  whatever  the  causes  of  those 
changes  may  be. 

Although  gray  tubercle  is  common  enough  in  children,  even  in 
the  youngest,  and  is  found  in  the  lungs  indifferently  with  the  other 
organs  of  the  body,  yet  chronic  pulmonary  phthisis  in  the  sense  of 
extensive  consolidation,  softening,  and  excavation,  cannot  be  con- 
sidered a  frequent  disease,  and  is  certainly  rare  under  the  age  of 
six  or  seven  years. 

Symptoms. — The  symptoms  of  pulmonary  phthisis  are  usually 
preceded  by  the  general  symptoms  which  have  been  described  as 
accompanying  tuberculosis.  After  these  have  continued  for  a 
variable  time,  special  symptoms  begin  to  be  noticed. 

One  of  the  first  signs  showing  that  the  lungs  have  become  impli- 
cated in  the  disease  is  cough.  In  the  beginning,  slight,  dry,  and 
short,  it  becomes  after  a  time  moister  and  more  prolonged,  occur- 
ring sometimes  in  fits  like  those  found  in  whooping-cough,  and  this 
without  any  signs  of  enlargement  of  the  bronchial  glands.  In 
such  cases  the  fits  of  coughing  occur  in  the  morning  on  waking 
from  sleep,  and  are  due  to  a  great  accumulation  of  mucus  in-  the 
bronchi,  or  in  cavities  formed  by  the  softened  tubercle,  opposing 
the  entrance  of  air  into  the  minuter  ramifications  of  the  air- 
passages.  However  loose  the  cough  may  be,  it  is  seldom,  in  chil- 
dren under  seven  or  eight  years  old,  accompanied  by  expectora- 
tion, unless  vomiting  occur,  as  such  children  invariably  swallow 
the  sputum  as  it  reaches  the  mouth.  If,  however,  the  cough  pro- 
duces vomiting,  large  quantities  of  purulent  mucus,  more  or  less 
thick  and  viscid,  may  be  expelled. 

Haemoptysis  is  a  rare  symptom,  as  the  blood,  like  the  expecto- 
ration, is  almost  always  swallowed.  Sometimes,  however,  it  may 
occur  in  great  quantities  at  the  end  of  the  disease,  causing  death. 
It  is  seldom  seen  except  in  cases  complicated  with  great  enlarge- 
ment of  the  bronchial  glands,  and  is  then  probably  due  to  the 
glandular  rather  than  to  the  pulmonary  lesion.  In  infants  a  dis- 
charge of  blood  from  the  lungs  never  occurs  at  the  beginning  of 
the  disease.  In  children  of  seven  years  of  age  and  upwards  it  is 
seen,  according  to  MM.  Rilliet  and  Barthez,^  in  rare  instances,  but 
is  never  considerable. 

'  Maladies  des  Eufauts,  vol.  iii.  p.  687. 


PHYSICAL    SIGNS.  205 

The  respirations  are  usually  increased  in  rapidity,  rising  often  to 
thirty,  forty,  or  even  more,  in  the  minute.  This  acceleration  is 
not  necessarily  accompanied  by  any  feeling  of  dyspnoea,  and  in 
the  chronic  disease,  unless  the  structural  alterations  occupy  the 
greater  part  of  both  lungs,  is  seldom  the  cause  of  any  discomfort 
to  the  patient.  If  the  increased  rapidity  in  breathing  is  accom- 
panied by  much  fever,  it  will  often  be  found  to  be  due  to  the 
occurrence  of  some  inflammatory  complication,  as  bronchitis  or 
pneumonia. 

Vague  chest-pains  are  sometimes  complained  of  by  children  who 
are*  old  enough  to  make  their  uneasiness  known,  and  if  complained 
of  spontaneously,  are  of  some  importance.  They  seldom  last  long 
at  a  time,  but  disappear  and  return  irregularly. 

The  position  of  the- child  in  bed  offers  nothing  characteristic,  as, 
unless  the  dyspnoea  be  extreme,  he  will  usually  lie  indifferently 
on  one  side  or  the  other  without  reference  to  the  seat  of  disease. 
Sometimes  he  is  found  to  assume  persistently  some  particular 
attitude ;  in  such  cases  there  is  commonly  a  serious  lesion  on  the 
side  to  which  he  is  inclined. 

When  the  disease  is  advanced  the  appetite  often  fails,  but  not 
always;  it  may  continue  good  almost  to  the  last,  and  the  more 
chronic  the  case,  the  more  likely  is  the  appetite  to  be  preserved. 
The  amount  of  fever  varies;  the  temperature  is  usually  higher 
than  that  of  health,  although  it  may  not  remain  at  the  same  eleva- 
tion throughout  the  day.  It  usually  rises  in  the  evening  to  over 
100°  Fahr.,  falling  again  towards  the  morning. 

Attacks  of  diarrhoea  are  very  common,  and  if  appearing  at  a 
period  subsequent  to  the  commencement  of  the  chest  symptoms, 
and  continuing  obstinate  in  spite  of  remedies,  are  probably  due  to 
tuberculous  ulceration  of  the  bowels.  The  emaciation  becomes 
more  and  more  marked,  and  all  the  symptoms  enumerated  under 
the  head  of  tuberculosis  are  aggravated. 

The  disease  may  last  months,  or  even  years,  ending  fatally  in 
the  great  majority  of  cases.  Death  takes  place  either  gradually 
without  great  aggravation  of  the  symptoms ;  or  preceded  by  much 
feeling  of  oppression  of  the  chest,  incessant  cough,  and  more  or 
less  pain ;  or  as  a  result  of  pneumothorax. 

Physical  signs. — The  physical  signs  of  pulmonary  phthisis  result 
partly  from  the  presence  of  tubercle  itself,  partly  from  the  occur- 
rence of  structural  changes  which  may  be  set  up  by  the  tubercle, 


206  CHROKIC    PULMONARY    PHTHISIS. 

and  are,  therefore,  secondary  to  it,  or  which  may  arise  independ- 
ently. The  evidence  obtained  by  inspection,  percussion,  and  aus- 
cultation of  the  chest,  shows  merely  the  presence  of  consolidation 
of  the  lungs,  of  breaking  up  of  the  consolidating  material  and  the 
formation  of  cavities,  without  any  reference  to  the  pathological 
lesion  by  which  these  changes  are  produced.  Whether  or  not 
they  are  due  to  tubercle  is  then  a  matter  of  inference  to  be  de- 
cided by  the  seat,  the  course,  etc.  of  these  physical  signs,  and  by 
other  considerations  which  will  be  afterwards  explained  under  the 
head  of  diagnosis.  In  infants  there  is  seldom  much  solidification 
of  the  lung ;  tubercle,  when  it  occurs,  is  scattered  generally  through 
the  organ  without  producing  any  alteration  of  the  percussion-note,  or 
any  auscultatory  signs  which  can  be  looked  upon  as  characteristic ; 
the  other  lesions  productive  of  chronic  consolidation  are  in  them 
exceedingly  rare.  In  older  children  there  is  greater  tendency  to 
the  grouping  of  tubercle,  the  other  causes  of  consolidation  are 
more  common,  and  at  about  six  or  seven  years  of  age  the  physical 
signs  are  very  much  the  same  as  those  found  in  the  adult. 

If  the  tubercles  are  sufficiently  aggregated  to  give  rise  to  physical 
signs,  or  if  any  other  cause  of  solidification  exists,  it  is  usually  at 
the  apices  of  the  lungs  that  the  signs  are  best  marked.  In  such 
cases  we  find  more  or  less  flattening  on  one  or  both  sides  under  the 
clavicle  and'  inspiratory  expansion  may  be  diminished  in  degree. 
If  the  child  speaks  or  cries  loudly,  vocal  fremitus  can  be  some- 
times detected ;  this  is  a  very  important  sign,  for  in  health,  on 
account  of  the  quality  of  the  voice  in  children,  vocal  vibration  is 
so  weak  as  to  be  almost  imperceptible.  When  present,  it  is,  there- 
fore, evidence  of  very  great  value  in  the  diagnosis  of  consolidation, 
while  at  the  same  time  its  absence  is  no  proof  that  the  lungs  are 
healthy.  On  percussion  there  is  dulness  over  the  seat  of  disease. 
At  the  apices  dulness  is  best  detected  in  infants  and  young  children 
at  the  supra-spinous  fossae,  and  can  often  be  discovered  at  these 
spots  when  in  front  the  percussion-note  is  perfectly  healthy.  Great 
care  must,  however,  be  taken  to  exclude  all  sources  of  fallacy  in 
estimating  the  degree  of  resonance  of  the  apices.  One  shoulder 
higher  than  the  other,  or  a  cramped  position,  bringing  the  muscles 
attached  to  the  shoulder  into  action,  will  produce  a  dull  sound  on 
percussion  which  is  not  due  to  the  condition  of  the  lung.  In 
infants,  in  examining  the  supra-spinous  fossiB,  it  is  advisable  to 
place  the  child,  stripped  to  the  waist,  on  his  mother's  left  arm,  so 


PERCUSSION.  207 

that  his  head  and  right  arm  hang  over  her  left  shoulder,  the  left 
arm  of  the  child  being  round  his  mother's  neck.  In  this  position 
the  muscles  of  both  sides  are  relaxed,  and  if  the  child  remains 
quiet  in  that  position,  the  results  of  percussion  may  be  relied  upon. 
Percussion  should  be  made  upon  the  two  sides  at  the  same  period 
of  the  respiratory  movement.  Thus,  if  one  side  has  been  percussed 
during  inspiration,  it  will  be  necessary  to  wait  until  another  breath 
is  taken  before  subjecting  the  opposite  side  to  the  same  test.  On 
account  of  the  readiness  with  which  false  conclusions  may  be  drawn 
with  regard  to  the  degree  of  resonance  of  the  lung  in  children,  it 
is  best  to  require  a  considerable  amount  of  dulness  on  percussion 
before  making  any  positive  inferences  from  the  examination. 
Slight  differences  between  the  two  sides  should  be  allowed  little 
weight,  for  a  spot  which  appeared  to  be  dull  on  one  visit,  may  on 
the  next  seem  perfectly  healthy ;  the  difference  probably  depend- 
ing upon  varying  degrees  of  expansion  of  the  lung-tissue  at  that 
spot. 

The  dulness,  although  usually  situated  at  the  apex  in  children 
as  it  is  in  adults,  is  not  necessarily  so.  The  whole  chest  should  be 
carefull}'-  percussed,  both  at  the  back  and  at  the  front.  Dulness 
may  be  found  in  spots  scattered  here  and  there  about  the  lungs, 
the  percussion-note  over  the  surrounding  tissue  being  natural  or 
even  abnormally  resonant  from  emphysema.  Broad  percussion 
upon  three  fingers  should  always  be  practised  in  addition  to  the 
ordinary  method,  as  dulness  may  be  often  detected  by  this  means 
where  percussion  upon  one  finger  alone  gives  no  very  positive 
result.  Immediate  percussion  is  also  often  useful,  and  Dr.  Bu- 
chanan^ prefers  this  method  in  thin  children,  to  the  use  of  the  left- 
hand  finger  as  a  pleximeter. 

Of  the  varieties  of  the  percussion-note  little  need  be  said.  To 
the  tubular  note  no  importance  can  be  attached  ;  and  the  crack-pot 
sound  is  a  natural  condition  if  the  chest  be  percussed  during  expi- 
ration, when  the  mouth  is  open. 

In  practising  auscultation  in  children,  it  is  often  recommended  to 
apply  the  ear  directly  to  the  chest  instead  of  using  a  stethoscope, 
on  account  of  the  uneasiness  caused  by  the  pressure  of  the  instru- 
ment exciting  crying.     The  advantages  of  such  a  course  are,  how- 

Lettsomian  Lectures  on  the  Diagnosis  and  Management  of  Lung  Diseases  in 
Children,  Lecture  L,  Lancet,  Jan.  25,  1868. 


208  CHRONIC    PULMONARY    PHTHISIS. 

ever,  more  ttan  counterbalanced  by  its  disadvantages.  Owing  to 
the  small  size  of  the  thorax  in  children,  and  to  the  readiness  with 
which,  in  them,  sounds  from  the  nose,  the  larynx,  and  the  throat, 
are  transmitted  to  the  chest,  it  is  extremely  important  to  circum- 
scribe as  much  as  possible  the  limits  within  which  the  different 
respiratory  sounds  are  perceived.  If  the  instrument  is  spoken  of 
as  a  "  trumpet,"  children  who  are  old  enough  to  understand  the 
term,  seldom  manifest  much  opposition  to  its  use,  especially  if 
they  are  allowed  to  touch  and  play  with  it  beforehand  ;  and  infants 
in  whom  the  chest-disease  is  extensive,  are  often  remarkably  quiet 
during  examination,  being  usually  too  much  occupied  by  their 
own  sensation  to  make  any  resistance  to  the  operation.  Over  the 
seat  of  dulness,  the  respiratory  murmur  is  found  to  be  weak  or 
suppressed,  or  is  bronchial,  blowing,  or  cavernous,  with  increased 
resonance  of  voice  and  cry.  As  the  tissue  softens  and  breaks  up, 
moist  crackles  are  heard  accompanying  the  breath-sounds,  or  there 
is  merely  a  click  or  two  at  the  end  of  inspiration.  This  passes,  as 
cavities  form,  into  gurgling,  or  large  bubbling  rhonchus  more  or 
less  metallic. 

The  stethoscopic  signs  differ  in  value  according  to  the  part  of 
the  chest  at  which  they  are  heard.  At  the  apices,  mere  harshness 
of  respiration  is  insignificant,  and  prolonged  expiration  absolutely 
worthless,  as  a  means  of  diagnosis.  Bronchial  breathing  is  a 
natural  condition  between  the  scapulae  over  the  site  of  the  prin- 
cipal division  of  the  air-tubes,  and  at  the  apices  may  be  closely 
simulated  by  sounds  conducted  from  the  larynx.  It  is  advisable 
that  the  child's  mouth  should  be  open  during  auscultation  of  the 
chest,  the  laryngeal  sounds  are  then  less  readily  transmitted.  In 
the  case  of  infants,  however,  this  is  not  easy  to  manage. 

Bronchial  breathing,  if  heard,  at  the  supra-spinous  fossae,  and 
supposing  that  conduction  from  the  larynx  can  be  excluded,  is 
often  the  sign  of  a  cavity.  In  the  case,  however,  of  bronchial, 
blowing,  and  cavernous  breathing,  enlarged  bronchial  glands  in 
contact  on  one  side  with  the  air-tubes,  and  on  the  other  with  the 
chest-wall,  may,  by  their  conducting  power,  simulate  these  varie- 
ties of  respiration  so  closely,  that  at  a  single  examination  it  is 
impossible  to  give  a  positive  opinion  as  to  the  condition  of  the 
lung  beneath.  It  is  only  by  careful  observation  of  the  succession 
of  these  sounds  that  a  conclusion  can  be  arrived  at.  In  the  case 
of  pulmonary  consolidation  and  excavation,  there  will  as  time  goes 


VALUE    OF    PHYSICAL    SIGNS.  209 

on,  be  a  gradual  progression  from  harsh  to  cavernous  breathing, 
while — if  the  sounds  are  due  to  conduction — cavernous,  bronchial, 
and  harsh  breathing  will  be  found  to  alternate  irregularly  with  one 
another.  The  results  of  percussion  often  aftbrd  no  assistance  in 
these  cases,  for  if  much  healthy  lung  intervene  between  the  dis- 
eased spot  and  the  surface,  or  if  the  disease  has  excited  compen- 
sating emphysema  around  it,  the  percussion-note  may  be  almost 
healthy. 

All  the  signs  of  a  cavity  may  be  produced  by  extensive  pleuritic 
effusion.  The  diagnosis  between  these  two  conditions  will  be 
given  afterwards. 

Bronchial  breathing  is  most  significant  of  solidification  when 
heard  at  the  base.  If  heard  at  the  apex,  in  front  or  behind,  con- 
duction from  the  larynx  and  enlarged  bronchial  glands  must  be 
excluded  before  laying  much  stress  upon  this  sign  as  evidence  of 
consolidation. 

Cavernous  respiration  at  the  base  is  very  suspicious  of  a  cavity ; 
at  the  apex  it  is  only  valuable  after  exclusion  of  enlarged  bronchial 
glands  and  pleuritic  effusion. 

In  the  case  of  disseminated  miliary  tubercles,  the  physical  signs 
are  very  much  more  obscure.  There  may  be  absolutely  nothing 
about  the  chest  from  which  any  information  can  be  obtained;  the 
resonance  may  be  perfect,  the  respiratory  sounds  natural,  and  a 
little  sonorous  or  submucous  rhonchus  heard  here  and  there,  show- 
ing the  presence  of  an  excess  of  secretion  in  the  air-tubes,  may  be 
the  only  signs  to  indicate  that  the  lungs  are  not  in  a  condition  of 
the  most  perfect  health.  At  other  times  the  submucous  rhonchus 
may  be  more  general,  and  may  be  heard  from  apex  to  base  in  both 
lungs ;  or  sibilant  and  sonorous  rhonchi  may  be  equally  exten- 
sively audible ;  or  the  respiration  may  be  weak  or  harsh  over  a 
variable  extent  of  lung-surface. 

Weak  respiration  is  of  greater  value,  as  evidence  of  tubercle,  at 
the  base  than  at  the  apex ;  but  at  a  first  examination  too  much 
importance  should  not  be  attached  to  it.  If  it  is  found  to  persist 
for  several  weeks,  or  if  it  occupies  the  whole  extent  from  apex  to 
base,  on  one  side  only,  it  becomes  a  sign  of  considerable  signifi- 
cance. Harsh  respiration  is  of  little  value  unless  it  passes  into 
weak  respiration  at  the  same  spot,  or  unless  the  breathing  is  weak 
in  intensity  and  harsh  in  quality  at  the  same  time :  it  then  be- 
comes of  more  importance. 
14 


210  CHRONIC    PULMONARY    PHTHISIS. 

Anato'nikal  Cliaraders. — The  first  stance  in  the  anatomical  chansres 
depending  upon  pulmonary  phthisis  consists  in  the  presence  of 
solid  bodies  of  variable  size  scattered  throus^h  the  luna:,  or  col- 
lected  into  groups  in  one  particular  lobe.  These  bodies  consist  of 
gray  or  yellow  miliary  tubercle,  and  of  the  large  masses  resulting 
from  scrofulous  pneumonia — the  infiltrated  yellow  tubercle  of  older 
pathologists. 

Gray  granulations  are  scattered  through  the  lungs,  but  are 
usually  in  greatest  quantity  in,  or  may  be  even  altogether  limited 
to,  the  upper  lobe.  They  occupy  the  septa  between  the  air  vesicles 
and  the  submucous  tissue  of  the  minuter  ramifications  of  the 
bronchi. 

Yellow  granulations  are  also  often  disseminated  through  the 
lungs.  They  are  not  always  the  result  of  conversion  of  the  gray  ; 
or  at  any  rate  small  yellow  bodies,  distinguishable  with  great 
difficulty  from  degenerated  gray  tubercle,  may  be  produced  by 
other  means.  Such  bodies  may  be  the  result  of  more  or  less  ex- 
tensive pneumonia  occurring  in  scrofulous  and  tuberculous  sub- 
jects. In  this  form  of  lung-inflammation,  described  by  Dr.  Andrew 
Clark  as  "  epithelial  pneumonia"^  (the  scrofulous  pneumonia  of 
some  authors),  the  air  vesicles  are  found  to  be  filled  up  with  a 
yellow  matter,  which  is  seen  under  the  microscope  to  consist  of 
large  epithelium-like  cells  containing  one  or  two  nuclei,  of  the 
same  cells  in  a  state  of  disintegration,  of  free  nuclei,  and  of  granu- 
lar matter.  If  isolated  air- vesicles  are  the  seat  of  this  inflammation, 
their  contents  are  seen  as  small  projecting  bodies  about  the  size  of 
a  millet-seed — larger,  if  contiguous  vesicles  are  affected — yellow, 
hard,  and  resistent  to  pressure.  When  pricked,  a  yellow  purulent- 
looking  fluid  sometimes  escapes,  if  the  formation  be  very  recent. 
The  coalescence  of  neighboring  vesicles,  filled  with  the  same  mate- 
rial, produces  masses  of  yellow  cheesy-looking  matter,  which  vary 
in  size  according  to  the  extent  of  tissue  involved  in  the  inflamma- 
tion. Every  degree  of  bulk  is  therefore  found  between  the 
solitary  millet-seed  bodies  and  extensive  consolidation  of  an  entire 
lobe,  or  even  of  the  whole  lung. 

The  masses  may  occupy  any  part  of  the  lung.  They  may  be 
seen  on  the  surface  as  flattened  plates,  extending  inwards  for  some 
distance  into  the  substance  of  the   organ,  and  having  a  notched, 

.'  Lectures  at  the  Royal  College  of  Physicians,  1866. 


ANATOMICAL    CHARACTERS.  211 

irregular  circumference,  or  in  the  interior  as  rounded  nodules.  Sur- 
rounding  them  may  be  healthy  tissue,  or  tissue  occupied  by  smaller 
masses  of  the  same  kind,  or  by  true  gray  tubercle.  The  solidified 
tissue  may  be  at  the  base  or  the  apex,  and  in  one  lung  or  in  both ; 
usually  only  in  one. 

When  a  section  is  made  of  one  of  these  masses,  the  surface  is 
found  to  be  dry,  of  a  straw  or  gray  color,  and  sometimes  marked 
with  streaks  or  spots  of  black  pigment.  The  fracture  is  granular, 
and  the  substance  breaks  down  under  pressure  the  more  easily  in 
proportion  to  the  newness  of  its  formation  ;  for  as  time  goes  on  the 
material  is  found  to  become  tougher  and  denser,  less  granular  and 
more  opaque.  Often  the  lobules,  by  coalescence  of  which  the  mass 
is  formed,  can  be  distinctly  traced  out,  depressed  intersecting  lines 
being  seen,  which  are  the  areolar. partition  separating  the  lobules 
from  one  another. 

This  cheesy  infiltration  is  not  necessarily  the  result  of  any  spe- 
cial variety  of  pneumonia.  Any  form  may  under  certain  condi- 
tions undergo  the  cheesy  transformation,  but  of  no  pneumonic  con- 
solidation can  such  a  degeneration  be  said  to  be  the  necessary  and 
inevitable  consequence.  Under  favorable  circumstances  a  pneu- 
monic deposit  is  removed  through  liquefaction  of  its  cells,  which, 
becoming  filled  with  fat  globules,  disintegrate  and  disappear. 
Under  favorable  circumstances;  however,  the  fatty  change  which 
begins  in  the  cells  becomes  arrested,  and  the  cells,  losing  their 
water,  shrink  and  dwindle  into  irregular-shaped  corpuscles. 

It  is  in  catarrhal  or  lobular  pneumonia  that  the  deposit  is  most 
frequently  found  to  become  cheesy,  and  the  more  chronic  the  in- 
flammatory process  remains,  the  less  likely  is  the  deposit  to  be  re- 
moved. But  catarrhal  pneumonia  of  the  most  chronic  kind  will 
often  end  favorably ;  indeed  in  children  there  appears  to  be  abso- 
lutely no  limit  beyond  which  such  a  deposit,  so  long  as  it  remains 
indolent,  may  not  become  completely  reabsorbed  :  at  least,  physical 
signs  of  lung  consolidation  may  disappear  altogether  after  remain- 
ing unchanged  for  many  months. 

The  consolidation  resulting  from  the  pneumonic  process  may  be 
the  only  pathological  condition  found,  or  it  may  be  accompanied 
by  true  gray  or  yellow  tubercle.  It  is  not  uncommon  to  find  the 
two  conditions  combined,  for  the  presence  of  a  cheesy  infiltrated 
deposit  appears  to  be  a  determining  cause  of  the  development  of 
true  tubercle,  which  may  then  be  looked  upon  as  a  secondary  for- 


212  CHRONIC    PULMONARY    PHTHISIS. 

mation.  Besides,  the  tubercle,  originally  uncomplicated,  may  ex- 
cite inflammation  in  the  lung  tissue  around  it;  its  bulk  will  then 
be  increased  by  pneumonic  solidification  forming  at  its  circumfer- 
ence. Consolidation  of  considerable  extent  may,  however,  result 
from  the  aggregation  of  the  tubercles  in  one  part  of  a  lung  with- 
out the  supervention  of  pneumonia.  This  usually  occurs  at  the 
apex,  and  the  detection  of  the  true  character  of  the  consolidation 
is  one  of  the  most  difficult  questions  in  the  diagnosis  of  pulmonary 
phthisis. 

After  the  consolidation,  tubercular  or  other,  has  existed  for  some 
time,  certain  changes  take  place  in  it.  Of  these,  the  most  common 
is  softening.  The  softening  begins  usually  in  the  centre  of  the 
mass,  whether  that  be  large  or  small,  and  a  communication  being- 
established  with  a  bronchial  tube,  the  softened  matter  is  expelled, 
and  a  cavity  results.  The  masses  situated  nearest  to  the  apex  are 
commonly  the  earliest  to  liquefy,  but  not  always.  Sometimes 
general  softening  appears  to  attack  all  the  solidified  patches  of 
tissue,  and  the  lung  is  then  found  to  be  riddled  with  abscesses 
which  communicate  with  another. 

The  cavities  vary  in  size  according  to  the  size  of  the  mass  which 
has  undergone  liquefaction.  The  smallest  are  about  the  size  of  a 
pea ;  the  largest  may  be  as  big  as  an  orange.  If  small,  they  are 
usually  numerous:  if  large,  the  number  is  less.  Sometimes  a 
large  cavity  is  seen  surrounded  by  smaller  ones  which  communi- 
cate with  it.  If  the  cavity  is  situated  in  the  interior  of  the  lung, 
it  is  surrounded  by  solidified  and  softened  tissue.  If  on  the  sur- 
face, it  is  covered  on  one  side  by  the  pleura,  and  unless  adhesion 
takes  place  between  the  opposed  surfaces  of  the  pleura,  perfora- 
tion readily  results.  Stretching  across  the  hollow  of  the  cavity 
are  often  seen  slender  bridges  of  lung-tissue,  containing  blood- 
vessels obliterated  or  still  permeable.  This  is  a  condition  much 
more  common  in  the  child  than  in  the  adult. 

A  lining  membrane  is  usually  described  as  belonging  to  cavities 
in  the  lung.  Dr.  Andrew  Clark,  however,  believes  this  view  to  be 
incorrect.  The  wall  consists  of  the  ordinary  tissue  of  the  lung, 
loaded  with  tubercular  or  other  matters.  Of  this  diseased  tissue, 
the  innermost  layer  is  in  a  state  of  disintegration,  and  can  some- 
times, although  not  always,  be  stripped  off':  hence  the  idea  of  its 
being  a  lining  membrane.  The  secretion  he  believes  not  to  be  a 
real  secretion,  but  to  consist  of  the  softened  part  of  the  disinte- 


SOFTENING    AND    EXCAVATION.  213 

grated  layer,  which,  becoming  liquid,  is  expectorated.  New  infil- 
tration goes  on  at  the  circumference  of  the  wall  of  the  cavity,  and 
continued  disintegration,  producing  more  and  more  of  the  so-called 
secretion,  on  the  inner  side.  If  the  infiltration  is  greater  propor- 
tionately than  the  disintegration,  the  cavity  becomes  smaller,  and 
may  even  almost  close.  If  the  disintegration  is  greater  than  the 
infiltration,  the  cavity  extends. 

It  is  the  larger  masses  in  the  lung  which  are  especially  prone  to 
disintegrate  and  soften  down :  the  consolidation  resulting  from 
scrofulous  pneumonia,  unless  a  favorable  change  take  place,  and  it 
be  reabsorbed,  almost  always  undergoes  this  change.  In  the  case 
of  the  gray  and  yellow  granulations,  other  alterations  may  take 
place.  They  may  become  inspissated  by  absorption  of  their  watery 
parts,  and  remain  as  little  opaque,  grayish,  hard  lumps.  This  is 
not  an  uncommon  change  in  the  gray  granulation.  Or  they  may 
become  cretaceous,  being  converted  into  small,  dry,  white  masses, 
like  bits  of  chalk.  These  two  changes  are  equivalent  to  a  cure ; 
but  although  the  local  effects  of  the  disease  are  thus  rendered 
harmless,  the  disease  itself  may  still  continue,  and  new  gray  gran- 
ulations may  be  seen  surrounding  cretaceous  masses,  showing  that 
in  spite  of  the  local  effort  at  repair,  the  influence  of  the  tubercular 
diathesis  had  remained  as  powerful  as  before.  Even  cavities  some- 
times, although  rarely,  close  and  cicatrize.  In  such  cases,  a  fibrous 
nodule  is  found  in  the  site  of  the  cavity.  It  is  usually  small,  of  a 
whitish-gray  color,  and  has  often  fibrous  bands  radiating  from  it 
into  the  healthy  tissue.  The  small  bronchi  are  seen  to  end  abruptly 
at  the  cicatrix,  showing  where  they  had  been  cut  off  by  the  ulcer- 
ating process  at  the  time  of  formation  of  the  cavity.  The  exist- 
ence of  the  cicatrix  is  indicated,  if  it  be  near  the  surface,  by  puck- 
ering of  the  pleura  over  it. 

Besides  the  pathological  alterations  which  have  been  described, 
there  is  another  variety  of  pulmonary  phthisis,  which  is  found  in 
children  as  well  as  in  adults.  This  is  a  form  of  cirrhosis,  and  is 
the  condition  to  which,  under  the  name  of  fibroid  phthisis,^  atten- 
tion has  been  lately  directed  by  Dr.  Andrew  Clark.  The  whole 
lung  is  diminished  in  size,  and  is  adherent  to  the  pleura.  A 
certain  portion — usually  the  lower  part — becomes  shrunken,  dense, 

I  Report  on  a  case  of  Fibroid  Phthisis,  by  Dr.  Andrew  Clark,  read  before  the 
Clinical  Society,  Feb.  14, 1868. 


214  CHRONIC    PULMONARY    PHTHISIS, 

and  slate-colored.  On  examination,  fibrous  septa  are  seen  passing 
in  different  directions  through  the  diseased  part :  some  horizontally, 
which  seem  to  consist  of  obliterated  vessels  and  bronchi  thickened 
by  adventitious  fibroid  tissue;  others  intersecting,  which  consist  of 
true  areolar  tissue,  and  occupy  the  interlobular  spaces,  ramifying 
in  varying  directions  from  them.  These  septa  inclose  portions  of 
lung  which  contain  yellow  cheesy  matter  in  a  state  of  disintegra- 
tion, or  are  broken  up  into  cavities.  The  bronchial  tubes  are  here 
and  there  dilated.  In  the  very  dense  part  of  the  lung  the  alveoli 
were  found  in  several  cases  by  Dr.  Andrew  Clark  to  be  filled  with 
'•'  what  seemed  an  amorphous  substance,  having  occasionally  an 
appearance  of  fibrillation." 

This  condition  of  the  lung  may  be  complicated  with  true  gray 
or  yellow  tubercle.  It  is  often,  however,  a  distinct  disease,  and 
may  thus  be  only  a  part  of  a  general  disorder  the  same  fibroid 
changes  going  on  in  other  organs,  as  the  kidney,  liver,  spleen,  &c. 

Diagnosis. — "^  ">e  diagnosis  of  pulmonary  phthisis  is  difficult  or 
easy  according'  o  the  amount  of  disease,  the  stage  which  has  been 
reached,  and  '  ne  exact  pathological  condition  which  gives  rise  to 
the  symptoms.  AYe  can  readily  detect  consolidation,  and  can  often 
determine  the  exact  structural  change  to  which  consolidation  is 
principally  owing ;  but  whether  or  not  it  is  entirely  due  to  this 
cause — whether  other  structural  alterations  may  not  be  present  to 
complicate  the  case — is  frequently  a  question  of  the  greatest  diffi- 
culty to  determine. 

In  all  cases  the  great  point  to  decide  is  the  presence  or  absence 
of  tubercle,  for  that  may  exist  alone,  or  may  accompany  the  other 
pathological  conditions  of  the  lung  which  have  been  described. 

When  tubercle  exists  alone,  disseminated  through  the  lungs,  it  is 
often,  owing  to  the  obscurity  of  the  physical  signs,  impossible  at 
the  first,  or  even  after  several  successive  examinations,  to  come  to 
any  positive  conclusion  as  to  the  exact  nature  of  the  disease.  To 
arrive  at  a  diagnosis  we  must  take  into  account  the  family  history, 
the  special  history,  the  conformation  of  body,  and  especially  the 
course  of  the  physical  signs.  Thus,  if  a  child,  born  of  con- 
sumptive parents,  and  whose  general  build  corresponds  to  the  type 
which  has  been  described  as  significant  of  the  tuberculous  diathesis, 
become  languid  and  mopes ;  if  he  has  irregular  attacks  of  febrile 
disturbance,  loses  flesh,  has  short,  drj'-  cough,  and  complains  of 
vague  pains  and  oppression  about  the  chest,  we  should  suspect 


DIAGNOSIS.  215 

plithisis.  If  these  symptoms  have  succeeded  to  an  attack  of  measles 
or  wtiooping-cough,  our  suspicions  are  strengthened  ;  but  so  long 
as  percussion  of  the  chest  shows  no  dulness,  and  auscultation 
reveals  nothing  but  harshness  of  respiration,  with  here  and  there 
dry  rhonchi,  there  is  nothing  upon  which  to  found  a  positive  diag- 
nosis. If  the  dry  sounds  become  replaced  by  submucous  rhonchus, 
there  is  still  nothing  which  may  not  be  accounted  for  by  ordinary 
catarrh  attacking  a  weakly  child.  If,  however,  the  dry  rhonchi 
persist  and  become  general,  being  heard  from  apex  to  base,  and  if 
this  condition  continues  without  improvement  for  several  weeks, 
and  without  moist  sounds  replacing  the  dry  rales,  the  case  assumes 
a  very  much  graver  aspect,  and  the  diagnosis  of  phthisis  becomes 
almost  a  certainty.  Such  cases  are,  however,  more  common  in  the 
acute  form  of  the  disease.  In  chronic  phthisis  the  tubercles  have 
a  greater  tendency  to  become  grouped  at  the  apices,  both  lungs 
being  affected.  Here  there  is  dulness  on  percussion,  and  the 
stethoscope  reveals  weak  or  bronchial  breathi*"^,  with  often  in- 
creased resonance  of  the  voice  or  cry.  The  du.  ]$s,  however,  to 
be  trustworthy,  must  be  well  marked:  slight  sha^^os  of  variation 
from  a  healthy  resonance  being  worthless  as  evidences  of  consoli- 
dation. Should  the  percussion  dulness  be  distinct,  and  the 
breathing  bronchial,  with  a  slight  crackle  at  the  end  of  inspiration, 
tiiese  signs  occurring  at  both  apices,  and  continuing  unchanged 
for  two  or  three  weeks,  become  satisfactory  evidence  of  tubercular 
consolidation.  On  the  other  hand,  absence  of  dulness  is  no  suffi- 
cient proof  of  the  absence  of  aggravated  tubercle,  for  the  reso- 
nance may  be  due  to  emphysema. 

In  cases  where,  from  the  ill-defined  character  of  the  physical 
signs,  we  had  been  obliged  to  reserve  an  opinion  as  to  the  condition 
of  the  apices,  the  occurrence  of  double  pneumonia  at  those  spots 
throws  considerable  light  upon  the  difficulty,  for  inflammation 
coming  on  under  such  circumstances  greatly  increases  the  proba- 
bilities of  tubercle. 

The  thermometer  is  of  little  value  in  the  diagnosis  of  pulmonary 
tubercle;  a  continued  elevation  of  temperature  shows  the  presence 
of  tuberculosis,  but  this  elevation  is,  according  to  Dr.  Ringer's'  in- 
vestigations, due  rather  to  the  general  condition  of  the  body  than 

'  On  the  Temperature  of  the  Body  as  a  Meaus  of  Diagnosis  in  Phthisis  and  Tu- 
berculosis.    London,  1865. 


216  CHRONIC    PULMONARY    PHTHISIS. 

to  the  actual  formation  of  tubercle  in  the  organs,  and  affords,  there- 
fore, no  distinct  indication  of  the  presence  of  tubercle  in  the  lungs. 
It  may  strengthen  our  suspicions,  but  that  is  all. 

In  scrofulous  pneumonia  (pneumonic  phthisis)  we  can  generally 
succeed  in  discovering  a  distinct  period  at  which  the  first  symp- 
toms were  noticed.  A  child,  delicate,  but  in  his  usual  health,  is 
seized  with  an  attack  of  vomiting,  followed  by  fever,  cough,  and 
general  chest  symptoms.  The  strength  is  not  much  reduced,  and 
the  breathing  is  but  little  oppressed,  although  it  may  be  rather 
more  hurried  than  natural. 

If  the  child  is  seen  early,  no  dulness  may  be  found  on  percus- 
sion, but  there  is  more  or  less  coarse  crepitation  heard  at  a  certain 
part  of  the  chest,  usually  at  one  or  the  other  apex — seldom  at  both 
if  the  disease  is  uncomplicated.  The  crepitation  accompanies  the 
expiration  as  well  as  the  inspiration,  and  varies  greatly  in  amount 
from  day  to  day,  sometimes  more  being  heard,  sometimes  less,  and 
sometimes  for  a  short  time  it  is  completely  absent.  If  any  dulness 
is  present,  it  is  slight  at  first,  and  may  not  become  more  marked 
for  several  weeks;  the  breath-sounds  are  not  necessarily  altered  in 
character.  The  temperature  of  the  body  rises  at  night  to  102°  or 
103°  Fahr,,  falling  in  the  morning  to  about  its  natural  level.' 

After  a  time,  often  only  after  several  weeks,  the  dulness  becomes 
more  marked,  and  then  gradually  increases  in  intensity  and  extent ; 
the  respiration  is  bronchial  or  tubular ;  and  the  coarse  crepita- 
tion, persisting,  is  heard  over  the  whole  of  the  consolidated  part, 
but  varying  in  amount  as  before,  and  occasionally  being  replaced 
for  a  time  by  a  rhonchus  of  larger  size.  Eventually  cavities  form  ; 
the  percussion-note  is  then  often  tubular,  and  there  is  cavernous 
respiration  with  gurgling. 

This  pneumonia  may  affect  any  part  of  the  lung,  but  it  usually 
attacks  the  apex  of  one  side,  and  is  seldom  found  in  both  lungs — at 
any  rate  at  first.     It  may  last  months  or  years. 

Here  we  get  a  series  of  signs  and  symptoms  which  differ  very 
markedly  from  those  found  in  simple  acute  pneumonia.  When 
the  case  is  seen  early,  the  slight  amount  of  weakness,  the  small  dis- 
turbance in  the  relation  between  the  pulse  and  the  respiration,  the 
fall  of  temperature  in  the  morning,  and  the  persistence  of  the  phy- 

'  On  some  Anomalous  Cases  of  Phthisis,  by  Sydney  Ringer,  M.  D.  Medical 
Times  and  Gazette,  Feb.  29,  18(i8. 


DIAGNOSIS    OF    SCROFULOUS    PNEUMONIA.  217 

sical  signs  and  the  symptoms  after  the  tenth  or  twelfth  day,  the 
time  at  which  in  simple  lobar  pneumonia  resolution  takes  place ; 
all  these  peculiarities  show  that  the  case  is  not  one  of  ordinary  in- 
flammation of  the  lung.  If  the  patient  is  seen  for  the  first  time  at 
a  later  period,  the  disease  may  be  distinguished  from  simple  pneu- 
monia by  the  length  of  time  during  which  it  has  lasted.  It  is  often, 
however,  dilBBcult  to  establish  a  distinct  connection  between  the 
previous  illness  and  the  present  symptoms,  and  the  case  may  be 
one  of  simple  pneumonia  complicating  an  already  existing  disease. 
Under  such  circumstances,  the  fact  of  crepitation  being  heard  over 
the  whole  of  the  consolidated  surface  instead  of  only  at  its  circum- 
ference, the  severity  of  the  physical  signs  in  comparison  with  the 
comparative  mildness  of  the  general  symptoms,  and  the  continu- 
ance of  these,  and  of  an  elevated  temperature,  after  the  time  when 
in  an  ordinary  case  resolution  might  be  reasonably  expected,  will 
serve  to  furnish  a  distinction. 

Between  commencing  scrofulous  pneumonia  of  the  apices  and 
gray  tubercular  formation,  the  diagnosis  is  much  less  easy.  The 
definite  period  of  commencement  would  lead  us  to  suspect  the 
former  disease,  but  so  long  as  there  are  no  very  positive  physical 
signs  it  is  necessary  to  reserve  a  decision.  Later,  when  the  dulness 
has  become  established,  and  all  the  signs  of  consolidation  are 
found,  the  want  of  correspondence  between  the  physical  signs  and 
the  general  symptoms,  the  limitation  of  the  disease  to  one  side,  and 
the  history  of  the  case  showing  the  absence  of  preliminary  failure 
of  health,  will  be  sufficient  grounds  for  the  diagnosis  of  scrofulous 
pneumonia.  It  is,  however,  by  no  means  uncommon  to  find 
scrofulous  pneumonia  occurring  as  a  complication  of  tubercle,  and 
the  presence  or  absence  of  tubercle  is  therefore  an  important 
question  to  decide  in  every  case  of  pulmonary  phthisis. 

If  the  apices  of  the  lungs  are  unaffected,  tubercle  may  be 
excluded. 

If  the  pneumonia  attacks  only  one  apex  the  presence  of  tubercle 
is  doubtful ;  but  if  after  several  months  the  opposite  apex  still  re- 
mains apparently  free  from  disease,  the  only  changes  being  an  ex- 
tension of  the  physical  signs  on  the  side  first  affected,  the  case  is 
probably  one  of  uncomplicated  scrofulous  pneumonia. 

If  both  apices  are  the  seat  of  inflammation,  the  presence  of 
tubercle  is  probable,  and  if  the  double   pneumonia   succeed   to 


218  CHROXIC    PULMONARY    PHTHISIS. 

already  suspected  tuberculous  disease  of  these  parts,  it  goes  far  to 
confirm  the  previous  suspicions. 

In  fibroid  phthisis  the  disease  is  limited  to  one  side.  The  affected 
side  is  retracted,  often  considerably  ;  the  front  of  the  chest  is  flat- 
tened, the  respiratory  movement  slight,  and  the  heart  more  or  less 
displaced.  If  the  disease  occupies  the  left  side  the  heart  is  drawn 
upwards,  if  the  right  side  the  heart  is  drawn  towards  the  middle 
line,  Eeal  elevation  of  the  heart  must  not  be  confounded  with 
apparent  elevation  through  unnatural  obliquity  of  the  ribs  occur- 
ring in  long-chested  children.  There  is  dulness  on  percussion 
over  the  seat  of  disease — usually  the  middle  third  of  the  lung  ap- 
proaching more  or  less  to  the  apex.  The  note  is  often  tubular, 
and  there  is  unusual  parietal  resistance.  Auscultation  shows 
harsh,  bronchial,  or  blowing  respiration,  with  coarse  rhonchus  and 
increased  resonance  of  voice,  passing,  as  cavities  form,  into  caver- 
nous respiration,  with  gurgling  and  pectoriloquy.  A  systolic  basic 
murmur  is  sometimes  present,  produced  probably  by  pressure. 
There  is  no  febrile  disturbance,  on  the  contrary  the  temperature  is 
unusually  low. 

In  extensive  consolidation  of  the  upper  part  of  one  side  only, 
the  other  side  giving  no — not  even  the  faintest — sign  of  disease, 
the  diagnosis  lies  between  scrofulous  pneumonia  and  fibroid 
phthisis.  The  existence  of  retraction  of  the  affected  side,  the 
altered  position  of  the  heart,  and  the  absence  of  fever,  exclude  the 
former  disease.  It  is  distinguished  from  chronic  pleurisy  with 
retraction  by  the  resonance  at  the  base,  and  by  the  signs  of  cavity. 

Tubercle  may  exist  in  combination  with  this  form  of  pulmonary 
phthisis,  and  should  always  be  suspected  "if  the  apex  of  the  dis- 
eased lung  is  involved  in  the  solidification."  The  probability  is 
increased  if  there  is  moist  crackling  in  the  supra-spinous  fossa,  and 
"if,  with  the  slightest  dulness  at  the  summit  of  the  opposite  lung, 
there  is  any  moist  crepitation,  doubt  is  practically  no  longer  possi- 
ble." The  above  sketch  of  fibroid  phthisis  is  taken  from  a  paper 
by  Dr.  Andrew  Clark  on  that  disease,  read  before  the  Clinical 
Society,  Feb.  28,  1868.  Dr.  Clark's  paper  referred  only  to  adults, 
but  the  disease  is  sometimes  found  in  children  of  six  or  eight  years 
and  upwards.  In  its  relation  to  them  the  subject  has  not  as  yet 
been  thoroughly  worked  out,  but  there  is  no  reason  to  believe  that 
they  are  affected  by  it  differently  from  their  elders. 

It  is  not  always  easy  to  satisfy  ourselves  as  to  the  existence  of  a 


DIAGNOSIS    OF    A    CAVITY.  219 

cavity  in  the  lung,  for,  although  present,  it  may  give  rise  to  no 
very  positive  signs,  and,  again,  although  absent,  the  physical  signs 
usually  indicative  of  excavation  may  be  present. 

In  infants,  and  children  of  three  or  four  years  old,  the  signs  of 
a  cavity  are  often  very  obscure,  consisting  merely  in  bronchial 
breathing  with  submucous  rhonchus  and  bronchophon3^  Here 
no  positive  opinion  should  be  hazarded.  It  must  be  remembered, 
however,  that  at  such  an  age  ulceration  of  the  lung  is  a  rare  con- 
dition. 

In  the  case  of  older  children  a  dull,  tubular,  or  tympanitic  per- 
cussion-note, with  gurgling  and  bronchophonic  resonance  of  the 
voice — signs  usually  indicative  of  a  cavity — may  be  produced  by 
dilated  bronchi,  and  are  occasionally  very  closely  simulated  in 
some  cases  of  pleuritic  effusion.  In  the  case  of  this  latter  disease 
cavernous  breathing,  with  large  metallic  bubbling  rhonchus,  and 
pectoriloquy,  may  be  sometimes  heard  at  the  upper  part  of  the 
affected  side,  and  may  then,  if  the  disease  is  chronic,  give  rise  to 
much  hesitation,  for  excavation  of  the  lung  may  be  an  accompani- 
ment of  the  empyema.  If,  however,  the  opposite  side  is  perfectly 
healthy,  and  especially  if  ordinary  vesicular  breathing  can  be 
detected  at  any  point,  however  limited,  of  the  apex  of  the  suspected 
lung,  a  cavity  may  be  excluded.' 

Between  the  dilated  bronchus  and  a  cavity  resulting  from  ul- 
ceration, the  diagnosis  is  extremely  difficult.  The  probabilities  are 
in  favor  of  dilated  bronchi  if  the  apex  of  the  affected  lung  appears 
healthy,  and  if  the  cavernous  signs  are  heard  at  about  the  middle 
of  the  lung,  and  give  the  idea  of  several  small  cavities  lying  in  a 
horizontal  or  diagonal  line.^  If  the  area  over  which  the  cavernous 
signs  are  heard  gradually  increases  in  extent,  our  suspicions  point 
to  a  cavity,  for  dilated  bronchi  may  remain  unaltered  for  months. 
In  all  cases  a  careful  examination  of  the  sputum  should  be  made 
with  the  microscope,  if  any  expectoration  can  be  obtained,  to 
search  for  fragments  of  elastic  tissue.  Such  fragments,  if  areolar, 
are  conclusive  evidence  of  ulcerative  excavation.^  In  cases,  also, 
of  empyema,  with  suspected  cavity,  the  presence  of  fragments  of 
elastic  tissue  in  the  sputum  will  at  once  decide  the  question  in 
favor  of  a  cavity.     It  is  necessary,  however,  to  make  many  exa- 

1  Rilliet  and  Barthez,  vol.  iii.  p.  680. 

2  Dr.  A.  Clark,  loc.  cit. 

3  Dr.  A.  Clark,  iu  Trausactlous  of  the  Pathological  Society  of  London,  1S55. 


220  CHRO^riC    PULMONARY    PHTHISIS. 

minations  of  the  same  sputum  before  deciding  against  the  presence 
of  the  elastic  tissue. 

Prognosis. — Pulmonary  phthisis  is  generally  fatal  sooner  or 
later,  but  its  course  from  bad  to  worse  is  not  always  uninterrupted. 
Great  caution  should  therefore  be  exercised  in  giving  a  prognosis, 
for  a  child  who  is  apparently  in  the  greatest  danger  may  suddenly 
begin  to  improve,  and  his  more  serious  symptoms  may  for  the 
time  completely  disappear.  Such  amendment  is  apt  to  excite 
amongst  his  friends  hopes,  seldom  destined  to  be  realized,  of  a 
complete  recovery. 

This  improvement  often  happens  in  cases  where  the  local  symp- 
toms are  temporarily  aggravated  by  a  bronchitic  attack,  but  it  may 
also  occur  in  cases  of  apparent  uncomplicated  gray  tubercle,  and 
it  is  not  so  very  uncommon  to  find  recovery  taking  place  in  cases 
which  present  all  the  characters  of  acute  tubercular  formation. 
When,  however,  the  chronic  disease  is  once  fairly  established,  the 
apparent  improvement  is  almost  always  speedily  followed  by  a 
relapse,  all  the  symptoms  returning  with  increased  severity. 

Pulmonary  phthisis  often  lasts  much  longer  than  could  be  ex- 
pected from  the  character  of  the  physical  signs.  A  child  may 
continue  in  the  same  state  without  much  improvement,  or  aggrava- 
tion of  his  symptoms,  for  years,  dying  eventually  of  tubercular 
disease  of  some  other  organ,  or  even  of  a  totally  different  com- 
plaint. It  becomes,  then,  a  question  of  much  importance  to  decide 
in  any  given  case  upon  the  prospects  of  a  lengthened  course,  and 
such  decision  will  depend  in  a  great  measure  upon  the  presence  or 
absence  of  gray  tubercle.  Uncomplicated  scrofulous  pneumonia 
is  often  very  sluggish  in  its  course ;  and  if  not  extensive  at  first, 
may  spread  over  the  lung  very  slowly.  It  is,  however,  always 
liable  to  take  on  suddenly  a  more  rapid  course,  and  too  great  con- 
fidence should  not  be  excited  by  the  apparent  inactivity  of  the 
disease. 

Fibroid  phthisis  is  still  slower  in  its  progress :  in  such  cases  the 
prognosis,  so  far  as  that  can  be  founded  upon  the  anatomical  cha- 
racters of  the  phthisis,  is  of  all  the  varieties  the  least  unfavorable. 

In  the  case  of  gray  tubercle,  either  alone  or  complicating  the 
other  varieties  of  pulmonary  phthisis,  very  little  hope  can  be 
given.  The  most  favorable  change  appears  to  be  its  complication 
with  fibroid  phthisis :  by  this  means  life  is  often  prolonged  for  a 
considerable  time.      The  presence  of   tubercle  in  other  organs, 


CAUSES.  221 

especially  the  bowels,  is  very  unfavorable.  Diarrhoea  is  not  un- 
frequently  the  direct  cause  of  death. 

Death  may  take  place  suddenly,  without  being  preceded  by 
any  great  aggravation  of  the  symptoms.  Usually,  however,  it  is 
ushered  in  by  increased  severity  of  the  cough,  sensation  of  oppres- 
sion about  the  chest,  lividity  of  the  face,  increasing  weakness,  and 
all  the  signs  of  exhaustion.  In  a  certain  proportion  of  cases  rup- 
ture of  the  lung  takes  place,  producing  pneumothorax :  this  is 
seldom  recovered  from. 

Causes. — Of  the  causes  of  pulmonary  phthisis,  so  far  as  that  is 
the  result  of  tubercle  of  the  lung,  nothing  need  be  added  to  what 
•has  already  been  stated  with  regard  to  tuberculosis.  Scrofulous 
pneumonia  may,  however,  arise  quite  independently  of  any  of  the 
causes  there  mentioned. 

Inflammation  of  the  lung  occurring  in  an  unhealthy  child  is 
seldom  simple.  The  deposit,  instead  of  becoming  absorbed,  is  apt 
to  remain  for  a  considerable  time,  then  slowly  to  degenerate,  and 
to  cause  ulceration  and  cavities,  which  spread  until  the  whole  lung, 
or  the  greater  part  of  it,  is  rendered  useless.  Besides  this  there  is, 
however,  another  means  by  which  the  same  pathological  condition 
may  be  set  up.  According  to  Dr.  Andrew  Clark,^  certain  dead 
animal  products  inserted  beneath  the  skin  of  a  rabbit  will  produce 
deposits,  first  in  the  lungs,  and  afterwards  in  other  parts  of  the 
body.  When  the  animal  is  healthy  these  become  absorbed :  when 
he  is  unhealthy,  or  being  healthy  is  kept  in  conditions  unfavorable 
to  health,  the  deposits  are  not  absorbed,  but  excite  secondary  de- 
posits in  other  parts.  The  same  thing  will  occur  in  the  human 
subject :  portions  of  septic  matter,  from  whatever  source,  retained 
in  contact  with  a  living  surface  may  become  absorbed,  and  may 
give  rise  to  "  secondary  deposits  in  the  lungs,  to  ulceration  in  the 
bowels,  to  clottings  in  vessels,  and  to  poisoning  of  the  blood."^ 
Dr.  Clark  has  shown  that  enlarged  tonsils  which  retain  their  secre- 
tions are  apt  to  become  loaded  with  an  offensive  cheesy  matter  in 
a  state  of  disintegration,  and  to  give  rise  to  a  curdy,  purulent 
discharge,  streaked  with  blood.  In  the  paper  just  referred  to.  Dr. 
Clark  describes  a  case  in  which  s-uch  tonsils  were,  with  an  orchitis, 
the  probable  cause  of  fatal  scrofulous  pneumonia.     The  pulmonary 

'  Lectures  delivered  at  the  Royal  College  of  Physiciaus,  18G6. 

2  See  a  paper  by  Dr.  A.  Clark,  in  the  Medical  Times  and  Gazette,  May  23, 1868. 


222  CHKONIC    PULMONARY    PHTHISIS. 

deposits  resulting  from  the  transference  of  these  septic  matters  to 
the  lung  undergo  disintegration,  excite  secondary  inflammation 
around  them,  and  set  up  the  pathological  changes  which  have  been 
described. 

In  scrofulous  children  tonsils  of  the  character  referred  to  are 
not  uncommon.  They  are,  besides,  subject  to  purulent  discharges 
from  the  ears,  nose,  and  vagina,  to  unhealthy  ulcerations  of  the 
skin  and  mucous  membranes,  and  to  suppurations  of  the  glands. 
It  is  possible  that  all  of  these  may  be  sources  from  which  absorp- 
tion can  occur  to  give  rise  to  pulmonary  deposits. 

Treatment. — The  directions  already  given  in  the  preceding  chap- 
ter, with  regard  to  the  prevention  and  treatment  of  tuberculosis, 
apply  with  equal  force  to  the  present  disease.  In  the  case  of  pul- 
monary phthisis  there  are,  however,  certain  precautions  which  it 
is  important  to  attend  to.  Thus,  when  the  shape  of  the  chest  is 
elongated,  and  narrowed  from  before  backwards,  showing  the  small 
size  of  the  lungs,  every  means  must  be  taken,  by  exercises  care- 
fully proportioned  to  the  strength  of  the  patient,  to  increase  the 
capacity  of  the  chest,  and  invigorate  the  muscles  of  respiration. 
This  is  effected  in  a  great  measure  by  general  exercise ;  but,  be- 
sides this,  the  more  special  exercises,  as  the  use  of  the  dumb-bells 
and  "of  the  "  chest-expander,"  are  particularly  valuable.  Drilling, 
fencing,  and  other  amusements  which  promote  the  acquirement  of 
a  good' carriage,  accustoming  the  child  to  throw  back  the  shoulders 
and  expand  the  lungs,  are  also  of  much  service.  The  exertion 
should  not,  however,  be  too  violent,  or  harm  rather  than  good  will 
result.  BrQathlessness,  or  a  feeling  of  oppression  about  the  chest, 
are  signs  of  labored  pulmonary  circulation,  and  should  at  once 
indicate  repose.  The  child  must  be  prevented  from  bending  over 
a  table  in  writing  or  drawing:  he  should  be  accustomed  to  stand 
at  a  desk,  breast-high,  while  pursuing  these  occupations,  so  that  the 
necessity  for  curving  his  body  may  be  avoided.  He  should  be 
taught  fully  to  expand  his  chest,  from  time  to  time,  by  occasional 
deep  inspirations  ;  and  singing  or  reading  aloud  are  also  advisable. 

Fresh  air  is  of  the  utmost  importance,  and  daily  exercise  in  the 
open  air  should  never  be  neglected  if  the  weather  is  not  damp. 
If  there  is  any  keenness  in  the  quality  of  the  air,  a  respirator  may 
be  used  to  warm  the  air  before  it  reaches  the  lungs. 

In  scrofulous  children  who  are  subject  to  inflammations  and 
suppurations,  and  to  caries  of  bone,  early  attention  must  be  paid 


TREATMENT — GENERAL    AND    SPECIAL.  223 

to  these  derangements.  The  child  must  be  kept  scrupulously 
clean,  and  any  discharges  from  the  ears,  nose,  or  vagina,  should  be 
at  once  treated  by  suitable  applications.  Where  disease  of  bone  is 
positively  ascertained,  Mr.  Holmes  recommends  early  removal  of 
the  whole  of  the  diseased  bone ;  as  internal  remedies,  such  as  cod- 
liver  oil  and  tonics,  although  useful  in  improving  the  general 
health  of  the  patient,  yet  appear  to  exercise  no  curative  influence 
upon  the  local  disease,  and  an  operation  becomes  imperative.^  For 
cheesy  tonsils.  Dr.  Andrew  Clark^  advises,  in  addition  to  general 
tonic  remedies,  alkaline  applications  to  the  throat,  and  gargles  of 
tannin  and  alum. 

The  action  of  the  skin  must  be  promoted  by  daily  sponging 
over  the  whole  body  with  tepid  water.  When  there  is  any  reason 
to  suspect  consolidation  of  the  lungs,  cold  baths  must  be  forbidden. 
The  shock  produced  by  the  first  contact  with  the  cold  water  at 
once  drives  the  blood  from  the  surface  to  the  interior,  and  causes 
a  sudden  increase  of  the  strain  upon  the  vessels  of  the  lungs,  as 
well  as  of  the  other  viscera.  Pulmonary  congestion  may  be  pro- 
duced by  this  means,  and  the  danger  of  hemoptysis  increased. 

With  regard  to  the  question  of  climate,  what  has  been  said 
when  speaking  of  tuberculosis  applies  equally  well  to  the  earlier 
stages  of  pulmonary  phthisis.  When,  however,  softening  of  the 
consolidating  matter  has  taken  place,  and  cavities  have  formed,  a 
warmer  climate  is  desirable ;  but  even  in  these  cases  there  are 
great  differences  in  different  patients,  and  some  will  require  a 
much  less  degree  of  heat  than  others.  Unless  there  be  great  irri- 
tability of  the  bronchial  mucous  membrane  dryness  of  the  air  is 
of  extreme  importance,  as  a  dry  air,  although  warm,  still  possesses 
bracing  properties.  If  the  lungs  are  very  irritable,  a  certain 
amount  of  moisture  is  of  service;  and  many  places,  both  in  Eng- 
land and  abroad,  are  recommended  for  such  cases.  If,  however,  a 
suitable  climate  can  be  found  in  their  own  country,  it  is  well  not 
to  send  these  patients  too  far  from  home ;  invalids  feel  acutely  the 
absence  of  home  comforts,  and  in  the  last  stage  of  the  disease 
especially,  when  little  good  can  be  hoped  for  from  travel,  it  is  cruel 
to  send  them  away  merely  to  die. 

To  improve  the  general  condition  of  the  patient  the  same  mea- 

'  Lancet,  1865,  vol.  i.  p.  59. 

2  London  Hospital  Reports,  vol.  i.,  1864. 


224  CHRONIC    PULMONARY    PHTHISIS. 

sures  must  be  adopted  as  have  already  been  recommended  for 
tuberculosis.  Our  first  attention  must  be  directed  to  the  digestive 
organs,  and  afterwards,  when  these  have  been  brought  into  a  more 
healthy  state,  cod-liver  oil,  iron,  and  other  tonics,  will  be  of 
service. 

With  regard  to  the  special  treatment  of  the  lung  affection  : — so 
long  as  there  is  fever,  with  dry  cough  or  scanty  expectoration,  and 
tightness  or  oppression  of  the  chest,  stimulant  expectorants  are 
inadmissible.  No  lowering  measures  should  be  employed,  it  is 
true  ;  but  while,  on  the  one  hand,  we  should  avoid  all  measures 
calculated  to  increase  the  depression  of  strength,  we  should  not, 
on  the  other  hand,  be  too  eager  to  administer  drugs  the  action  of 
which  would  be  to  increase  the  irritation  of  a  mucous  membrane 
already  in  a  state  of  active  congestion.  Opium,  although  it  allays 
for  the  time  the  irritability  of  the  bronchial  tubes,  is  also  unsuit- 
able, for  it  diminishes  expectoration,  and  the  secretions  would, 
therefore,  remain  in  the  tubes  to  be  a  source  of  continued  irrita- 
tion. In  such  cases  we  shall  best  relieve  the  engorged  state  of  the 
lung  by  the  administration  of  remedies  tending  to  produce  a 
copious  secretion  from  the  congested  mucous  membrane,  as  in  the 
following  mixture :' — 

IJ.  Liquor  ammonise  acetatis,  '^iv  ; 
Potas.  nitratis,  5j  ; 
Potas.  bicarbonatis,  ^jss  ; 
Sp.  ffitheris  nitrici,  5JS3  ; 
Aqufe  carui  ad  §vj.     M.  5SS  tertii  hora. 

At  the  same  time  the  chest  should  be  kept  covered  with  hot  lin- 
seed-meal poultices,  frequently  renewed ;  and  the  child  should  be 
confined  to  his  nursery  or  bed-room. 

After  the  cough  has  become  looser,  and  the  oppression  of  the 
chest  has  subsided,  expectorants  should  be  given  with  an  alkali : — 

I^.  Sp.  ammonise  aromat., 
Sp.  cctheris  nitrici, 
Viui  ipecacuanhse,  aa  3j ; 
Pot.  bicarbonatis,  5J  5 
Infusi  calumbffi  ad  §vj.     M.  ^ss  sexta  hora  ; 

and  afterwards,  when  the  secretion  is  free,  easily  brought  up,  and 
the  fever  has  disappeared,  an  astringent  may  be  prescribed,  with 
expectorants  and  a  little  opium  : — 

'  For  a  child  of  six  or  seven  years  old. 


COUNTER-IRRITATION.  225 

5.  Liq.  ferri  pernitratis, 

Acidi  nitiici  diluti,  aa  5j  5 

Tiiict.  camph.  c.  opio,  3ij ; 

Oxymel  scillae,  §j  ; 

Inf.  calumbae  ad  ^vj.     M.  §ss  ter  die. 

On  account  of  the  derangement  of  the  stomach,  which  is  so  apt  to 
be  produced  by  even  small  doses  of  the  nauseating  expectorants, 
such  as  ipecacuanha  and  squill,  it  is  advisable  to  combine  them 
with  tonics  when  the  state  of  the  patient  permits.  In  this  way 
they  are  better  borne  by  the  stomach,  and  cause  less  impairment  of 
the  appetite.  The  alkaline  mixtures  should  not  be  continued  too 
long:  when  the  secretion  is  quite  free,  as  shown  by  the  looseness 
of  the  cough,  the  ease  of  expectoration,  and  the  absence  of  fever, 
astringents  are  required  to  dry  up  the  secretion,  and  give  tone  to 
the  relaxed  mucous  membrane. 

In  cases  where  we  have  reason  to  believe  the  consolidation  to  be 
owing  to  unabsorbed  pneumonic  deposits,  alkalies  are  also  ex- 
tremely useful.  Dr.  Andrew  Clark^  recommends  a  mixture  con- 
taining bark,  iodide  of  potassium,  bicarbonate  of  potash  and 
ammonia,  until  the  urine  is  alkaline.  If  there  is  much  anaemia, 
he  substitutes  infusion  of  calumba  for  the  bark,  and  adds  a  few 
grains  of  citrate  of  iron  to  each  dose.  The  inhalation  of  sprays 
of  weak  solutions  of  bicarbonate,  nitrate,  or  chlorate  of  potash, 
seems  to  have  a  very  useful  effect  in  promoting  expectoration.  A 
solution  of  bicarbonate  of  potash,  ten  grains  to  the  ounce,  ma}'  be 
inhaled  in  this  way  twice  a  day.  At  a  later  stage  an  astringent 
spray  may  be  used,  as  three  grains  of  tannin  to  the  ounce  of  water. 

Counter-irritation  in  children  must  be  used  cautiously,  and  is 
seldom  necessary.  So  long  as  there  is  fever,  with  dry  cough,  etc., 
hot  linseed-meal  poultices  are  the  best  applications;  and  these 
combined  with  the  measures  described  above,  soon  relieve  the 
more  acute  symptoms.  Irritants  applied  to  the  chest  appear  to  be 
most  useful  in  cases  where  the  consolidation  is  pneumonic  in  char- 
acter. In  such  cases  a  liniment  of  croton  oil  (5j  in  oj  of  linimentum 
saponis)  may  be  rubbed  into  a  limited  spot  twice  a  day  till  pustu- 
lation,  and  then  once  a  day  for  a  week.  Dr.  Buchanan  states  that  he 
has  used  this  method  of  counter-irritation  to  children  under  two 
years  of  age.^  So  long,  however,  as  there  is  much  heat  of  skin, 
counter-irritants  should  not  be  employed. 

'  See  Lancet,  Oct.  20,  1866,  p.  439. 

2  Lecture  I.,  On  Diagnosis  and  Management  of  Lung  Diseases  in  Children. 
Lancet,  Feb.  1,  1868. 

15 


CHAPTER   X. 

TUBERCULIZATION   OF   GLANDS. 

TtTBERCDLiZATiON  OF  LYMPHATIC  Glands. — Of  glands  ID  generaL 

Of  Bronchial  Glands  or  Bronchial  Phthisis. — Symptoms — Produced  by  pressure 
on  neigbboring  organs — Pressure  on  veins — On  nerves — Pliysical  signs — 
Alterations  in  respiratory  sounds  produced  by  pressure  on  tracbea  and  broncbi 
— Modes  of  termination — Diagnosis.  , 

Tuberculization  of  Mesenteric  Glands  or  Mesenteric  Phthisis  (Tabes  Mesen- 
tn-icus). — Symptoms — General — Local — Pressure  on  veins — Ascites  usually 
tbe  result  of  peritonitis — Perforation  of  bowel — Diagnosis — Only  to  be  made 
by  feeling  the  glands — Diagnosis  from  fecal  accumulations — From  tubercle 
of  omentum. 

Anatomical  Characters  of  Enlarged  Tubercular  Glands. 

Treatment. 

The  lymphatic  glands  often  become  the  seat  of  tubercle,  not 
only  those  which  are  external,  but  also  those  occupying  the  thora- 
cic and  abdominal  cavities. 

In  children,  the  lymphatic  glands  are  exceedingly  liable  to 
become  enlarged  from  neighboring  irritation  or  inflammation, 
some  irritating  matters  being  conveyed  into  them  by  the  lym- 
phatics coming  from  the  inflamed  part.  This  is  well  seen  in  the 
case  of  impetigo  of  the  head  or  face,  when  the  glands  of  the  neck, 
or  those  under  the  chin — according  to  the  seat  of  the  eruption — 
become  actively  congested,  serum  is  poured  out,  lymph  is  exuded, 
and  the  size  of  the  glands  is  increased. 

In  tuberculous  children,  active  congestion  of  the  glands  tends  to 
the  formation  of  tubercle  within  them.  If,  then,  after  the  cure  of 
the  primary  disease  the  enlarged  glands  remain  large,  and  this 
increase  in  size  persists  for  a  long  time,  without  any  tendency  to 
diminish,  they  are  probably  tubercular.^  Such  glands  are  oval  or 
round,  hard,  uneven  on  their  surface,  and  their  outline  is  irregular. 
They  are  not  tender,  and  the  skin  over  them  is  colorless,  and  is 

'  Jenuer  on  Tuberculosis,  Medical  Times  and  Gazette,  Oct.  26, 1861. 


BRONCHIAL    PHTHISIS.  227 

not  adherent.  Occasionally  they  inflame  without  evident  cause : 
the  skin  then  becomes  red  ;  attaches  itself  to  the  gland  beneath  it ; 
an  abscess  forms,  bursts,  and  the  tuberculous  matter  is  expelled ; 
after  which  the  wound  heals,  or  a  small  opening  is  left  through 
which  a  discharge  occurs  from  time  to  time.  This  spontaneous 
inflammation  and  suppuration  of  a  chronically  enlarged  gland, 
should  always  lead  us  to  suspect  tubercle. 

Sometimes  several  glands  become  enlarged  and  unite,  forming  a 
mass,  the  separate  parts  of  which  are  connected  by  thickened  and 
condensed  cellular  tissue. 

Glandular  enlargement,  then,  is  always  an  indication  of  pre- 
existing inflammation  of  the  part  from  which  the  lymphatic  vessels 
which  pass  through  the  gland  have  taken  their  origin,  and  if  this 
enlargement  continues  a  long  time,  it  is  strong  evidence  of  tubercle. 
The  same  cause  produces  tuberculization  of  the  bronchial  and 
mesenteric  glands ;  catarrhs  or  inflammatory  affections  of  the  lungs 
in  the  one  case,  and  diarrhoea  or  intestinal  irritation  in  the  other, 
leading  to  the  tuberculous  condition. 

While,  however,  in  the  case  of  tuberculization  of  the  external 
glands,  no  other  ill  effects  follow  than  those  due  to  impairment  of 
function  in  the  glands  themselves,  in  the  case  of  the  bronchial  and 
mesenteric  glands,  other  evils  are  induced.  These  bodies — in- 
closed as  they  are  in  cavities,  and  in  contact  with  compressible 
organs — when  enlarged,  produce  by  their  pressure  secondary  dis- 
turbances, which  vary  according  to  the  organ  whose  function  is 
thus  interfered  with,  and  according  to  the  more  or  less  yielding 
material  of  which  the  walls  of  the  cavity  are  composed.  Enlarge- 
ment of  the  bronchial  glands  will  thus  produce  more  serious 
consequences — owing  to  the  resisting  parietes  of  the  chest — than 
the  same  condition  of  the  mesenteric  glands  which  are  confined  by 
the  more  distensible  wall  of  the  belly. 

Tuberculization  of  the  Bronchial  Glands,  or  Bronchial 
Phthisis. — Tubercular  disease  of  the  bronchial  glands  is  exceed- 
ingly common  in  consumptive  children,  as  shown  by  post-mortem 
examination;  but  an  amount  of  disease  so  great  as  to  be  detecta- 
ble during  life,  is  a  condition  much  less  frequently  met  with.  In 
order  to  afford  signs  of  its  presence,  the  disease  of  the  glands 
must  be  sufficient  to  produce  considerable  enlargement;  for  unless 
their  size  is  so  much  increased  as  to  produce  derangement  of 


228  TUBERCULIZATION    OF    GLANDS. 

function  in  neighboring  organs,  the  lesion  is  one  which  cannot 
be  satisfactorily  diagnosed. 

Symptoms. — After  a  child  has  been  sujQfering  for  some  time  from 
the  general  symptoms  of  tuberculosis,  certain  special  symptoms  be- 
gin to  be  noticed.  These  special  symptoms  may  best  be  grouped 
according  to  the  causes  which  produce  them.  Thus,  the  glands  by 
their  enlargement  may  press  upon  the  bloodvessels,  the  nerves, 
and  the  air-passages. 

Pressure  upon  the  superior  vena  cava,  or  upon  either  innominate 
vein,  interferes  with  the  return  of  blood  from  the  head  and  neck. 
As  a  consequence,  we  find  dilatation  of  the  veins  of  those  parts, 
and  more  or  less  lividity  of  the  face,  neck,  and  upper  part  of  the 
chest.  A  certain  amount  of  heaviness  and  stupor  may  be  pro- 
duced by  the  interference  with  the  return  of  blood  from  the  brain ; 
and,  if  the  pressure  be  great,  or  the  quality  of  the  blood  much 
impoverished,  puffiness,  or  even  oedema  of  the  face  may  be  found, 
first  appearing,  and  being  most  marked  about  the  eyelids.  If  only 
one  of  the  innominate  veins  is  exposed  to  pressure,  the  symptoms 
are  limited  to  one  side  only.  Enlargement  of  the  veins  of  one 
side  of  the  face  and  neck,  with  a  prominent  jugular  vein  on  that 
side,  should  always  lead  us  to  suspect  bronchial  phthisis.  The 
venous  engorgement  is  especially  noticeable  during  coughing. 

If  the  congestion  is  very  great,  rupture  of  small  vessels  may 
take  place,  and  bleeding  occur  from  the  nose  or  into  the  lungs. 
The  former  is  common,  but  the  latter  is  difficult  to  ascertain,  for 
children  almost  invariably  swallow  blood  coming  up  from  the  lungs. 
In  a  child  the  discharge  of  blood  from  the  mouth  during  coughing, 
is  seldom  evidence  of  haemoptysis.  It  is  almost  always  the  result 
of  epistaxis,  the  blood  flowing  down  into  the  back  of  the  throat 
through  the  posterior  nares. 

When  the  nerves  passing  through  the  chest  are  compressed,  one 
of  the  earliest  indications  of  such  pressure  is  a  peculiar  character 
of  the  cough.  The  cough  becomes  spasmodic,  occurring  irregu- 
larly in  paroxysms  like  those  of  pertussis,  lasting  only  a  short 
time,  and  ending  sometimes,  although  rarely,  in  a  crowing  inspira- 
tion. There  is  seldom  any  vomiting.  Sometimes  the  cough  is 
hoarse  and  dry ;  at  others  it  is  moist  with  a  rattling  of  mucus;  at 
others  again  its  quality  is  unchanged,  and  presents  nothing  to 
attract  attention.  The  voice,  like  the  cough,  may  be  altered  in 
character,  but  not  usually,  unless  the  disease  is  far  advanced.     It 


BRONCHIAL    PHTHISIS  —  PHYSICAL    SIGNS.  229 

may  become  hoarse  or  thick,  or  even  partially  extinct,  and  these 
different  conditions  frequently  alternate  with  one  another. 

Violent  attacks  of  dyspnoea  occasionally  occur,  and  may  assume 
all  the  characters  of  asthmatic  seizures;  the  face  becomes  livid, 
the  countenance  anxious,  and  the  skin  cool  and  damp.  Asthma 
in  young  children  not  unfrequently  owes  its  origin  to  this  condi- 
tion of  the  bronchial  glands.  Attacks  of  spasm  of  the  glottis 
sometimes  are  noticed;  according  to  Dr.  Ley/  laryngismus  stridu- 
lus is  constantly  produced  by  this  cause. 

Physical  signs. — The  enlarged  glands  are  seated  at  the  bifurca- 
tion of  the  trachea,  and  therefore  behind  the  first  bone  of  the 
sternum.  On  percussion  there  is  dulness  at  that  spot,  which  may 
extend  to  a  variable  distance  on  either  side,  and  below.  It  some- 
times reaches  from  the  sternal  notch  as  far  as  the  base  of  the 
heart.  Occasionally  there  is  dulness  also  between  the  scapulae, 
but  this  is  not  always  found  on  account  of  the  thickness  of  lung 
which  lies  between  the  glands  and  the  posterior  wall  of  the 
chest.  If  any  enlarged  glands  lie  underneath  the  anterior  mar- 
gins of  the  lungs,  a  "crack-pot"  sound  may  be  heard  on  per- 
cussion over  the  first  three  ribs.  This,  however,  on  account  of  the 
natural  pliancy  of  the  chest- walls  in  children,  is  a  common  circum- 
stance, and  is  not  necessarily  a  sign  of  disease. 

The  auscultatory  signs  are  due  partly  to  the  effects  of  pressure 
of  the  enlarged  glands  upon  the  trachea  and  bronchi ;  partly  to 
the  unnatural  distinctness  with  which  the  breath  sounds  are  con- 
veyed to  the  surface,  for  an  artificial  medium  of  conduction  is 
formed  between  the  tubes  and  the  wall  of  the  chest. 

Pressure  upon  the  lower  part  of  the  trachea  produces  during 
respiration  a  loud  snore,  which  differs  in  character  from  the  ordi- 
nary sonorous  rhonchus,  and  may  be  frequently  heard  at  a  distance 
from  the  chest.  It  is  sometimes  intermittent.  Upon  either  bron- 
chus pressure,  if  considerable,  causes  weakness  of  the  respiratory 
sound  in  the  corresponding  lung,  especially  at  the  base,  for  a 
certain  amount  of  collapse  of  the  inferior  lobes  of  the  lung  may 
take  place  with  sinking  in  of  the  lower  part  of  the  thoracic  wall 
at  the  side. 

If  there  is  no  pressure,  but  the  glands  adhere  closely  to  the 
bronchi  on  one  side,  and  to  the  chest-wall  on  the  other,  the  breath- 

'  London  Medical  Gazette,  1834. 


230  TUBERCULIZATION    OF    GLANDS. 

sounds  are  tubular  with  long  ringing  rhonchus,  in  front,  and  also, 
sometimes  between  the  scapulae  behind  ;  powerful  quasi-pectorilo- 
quous  bronchophony  may  also  be  produced.^ 

At  the  supra-spinous  fossge  the  sounds  may  be  weak,  bronchial, 
or  even  cavernous,  and  these  different  conditions  may  alternate 
irregularly  with  one  another.  A  hum  is  sometimes  heard  over  the 
position  of  the  descending  vena  cava  from  pressure  upon  the  vein ; 
and  compression  of  the  pulmonary  artery  produces  a  systolic  mur- 
mur heard  at  the  second  left  interspace. 

The  symptoms  of  bronchial  phthisis  are  blended  with  those  of 
the  general  disease,  and  are  often  masked  by  more  prominent 
symptoms  due  to  the  same  disease  of  other  organs,  especially  of 
the  lungs.  The  combination  of  pulmonary  with  bronchial  phthisis 
is  very  common,  and  the  physical  signs  of  the  former  disease  are 
often  perverted  and  exaggerated  by  this  condition  of  the  glands, 
as  has  already  been  described. 

Softening  of  the  enlarged  glands  may  take  place,  and  a  commu- 
nication be  set  up  with  the  lung,  producing  pneumothorax;  or 
with  a  large  vessel,  giving  rise  to  fatal  hemorrhage.  These 
methods  of  termination  are,  however,  rare.  Death  usually  takes 
place  with  aggravation  of  the  preceding  symptoms,  and  is  not 
unfrequently  hastened  by  accompanying  pulmonary  phthisis. 

Diagnosis. — •In  a  well-marked  case  the  signs  of  pressure  upon 
the  veins,  the  dulness  over  the  first  bone  of  the  sternum  extending 
to  a  variable  distance  on  each  side,  and  the  paroxysmal  cough,  point 
conclusively  to  bronchial  phthisis. 

Before  any  signs  of  pressure  exist,  and  before  the  size  of  the 
glands  is  increased  sufficiently  to  give  rise  to  alteration  of  the  per- 
cussion-note, the  only  symptoms  observable  are  those  of  tubercu- 
losis, and  present  nothing  characteristic.  The  first  symptom 
leading  to  suspicion  is  usually  the  peculiarity  in  the  cough.  This 
is  distinguished  from  the  cough  of  pertussis,  which  it  so  much 
resembles,  by  the  absence  of  crowing,  and  of  the  terminal  vomit- 
ing, or  glairy  expectoration.  Such  a  cough,  if  unaccompanied  by 
the  auscultatory  signs  of  pulmonary  disease,  is  very  distinctive  of 
enlarged  bronchial  glands.  The  absence  of  these  auscultatory 
signs  is  very  important  in  the  diagnosis,  as  a  morning  cough  of 
very  similar  character  is  occasionally  heard  in  cases  of  pulmonary 

'  Walshe  on  Diseases  of  the  Lungs.     Art.  Bronchial  Phthisis. 


MESENTERIC    PHTHISIS  —  SYMPTOMS.  231 

phthisis  with  excavation  of  the  lung,  and  is  sometimes  also  a  cha- 
racteristic of  broncho-pneumonia.  If  in  the  interval  of  the  fits  of 
coughing  there  is  anything  approaching  to  an  asthmatic  seizure, 
or  the  slightest  percussion-clulness  at  the  top  of  the  sternum,  little 
doubt  can  remain  as  to  the  nature  of  the  disease.  Alteration  in 
the  quality  of  the  voice  often  accompanies  the  characteristic  cough. 
If  there  is  doubt  in  any  case,  the  occurrence  of  signs  of  venous 
pressure  at  once  changes  our  suspicions  into  certainty. 

Mesenteric  Phthisis. — Tubercular  disease  of  the  mesenteric 
glands,  or  tabes  mesenterica,  is  very  far  from  being  a  common  dis- 
ease ;  at  any  rate  it  is  rare  to  find  enlargement  of  these  glands  so 
great  as  to  be  discoverable  by  the  touch,  and  unless  they  can  be 
felt,  it  is  impossible  to  say  with  anything  approaching  to  certainty 
that  they  are  enlarged  at  all.  Unless  enlarged,  their  influence 
upon  general  nutrition  is  probably  insignificant,  for  although  they 
may  not  be  quite  healthy,  yet  they  are  no  doubt  sufficiently  so  to 
carry  on  their  functions  with  more  or  less  completeness,  and  there- 
fore if  no  increase  in  size  can  be  discovered,  their  consideration 
may  be  passed  over,  as  far  as  regards  prognosis  or  treatment  of 
the  patient. 

Symptoms. — The  general  symptoms  are  those  belonging  to  the 
general  disease,  for  the  mesenteric  glands  are  only  one  of  many 
organs  the  seat  of  tubercle,  although  they  may  be  more  profoundly 
affected  than  other  parts  of  the  body.  There  is  usually  emacia- 
tion, as  there  is  in  all  cases  where  tubercle  is  present,  but  it  is  not 
more  marked  than  when  other  organs  are  more  prominently 
affected.  The  appetite  is  good,  sometimes  unusually  keen.  Thirst 
is  moderate.  The  tongue  is  pale,  clean,  and  often  slimy-looking, 
and  there  may  be  diarrhoea,  especially  if,  as  often  happens,  tuber- 
cular ulceration  of  the  bowels  is  a  complication  of  the  disease. 
Vomiting  is  a  rare  symptom. 

The  local  symptoms  are  the  only  ones  of  any  value  in  the  detec- 
tion of  tabes.  The  belly  is  at  first  unchanged  in  shape,  and  even 
as  the  disease  advances  does  not  necessarily  become  more  promi- 
nent. On  the  contrary,  the  abdominal  wall  is  often  retracted,  and 
when  swollen  it  may  be  soft  and  easily  depressed,  although  it  is 
apt  to  become  tense  at  times  from  the  accumulation  of  flatus  in 
the  bowels.  The  wall  may  also  be  tense  when  the  size  of  the 
glands  is  very  considerably  increased.  The  degree  of  tension  of 
the  parietes  is  very  important,  as  regards  the  detection  of  the  en- 


232  TUBERCULIZATION    OF    GLANDS. 

largement.  If  the  tension  be  very  great,  a  moderate  enlargement 
may  escape  notice,  owing  to  the  resistance  of  the  abdominal  walls, 
which  will  not  allow  the  glands  to  be  reached  by  the  finger ;  and 
a  tumor  which  can  be  easily  felt  at  one  visit  may  at  the  next  be 
completely  concealed  by  the  abdominal  inflation,  so  as  to  be  no 
longer  detectable  by  the  touch. 

The  situation  of  the  tumor  is  about  the  umbilicus;  the  swelling 
is  irregular  to  the  feel,  and  hard.  Its  size  varies,  but  may  be  as 
large  as  a  foetal  head.  When  the  mass  is  large,  it  can  best  be  de- 
tected by  pressing  the  abdominal  wall  inwards  towards  the  spinal 
column.  When  small,  Sir  William  Jenner^  recommends  that  the 
parietes  should  be  grasped  by  the  fingers  and  thumb  of  one  hand, 
or  between  the  fingers  of  the  two  hands,  and  pressure  thus  be 
made  laterally,  from  the  sides  towards  the  centre,  so  as  to  seize  the 
tumor  between  the  fingers.  By  this  means  a  swelling  the  size  of 
a  nut  can  be  felt,  if  the  wall  is  flaccid.  The  glands  are  sometimes 
slightly  movable,  if  the  enlargement  is  not  sufficiently  great  to 
involve  the  mesentery  in  the  swelling. 

There  is  usually  more  or  less  tenderness  on  pressure,  but  the 
tenderness  is  not  necessarily  a  sign  of  inflammation  of  the  dis- 
eased glands,  for  it  is  found  in  cases  where  no  trace  of  inflammation 
is  discoverable  on  a  post-mortem  examination. 

When  the  glands  reach  a  considerable  size,  they  may  press  upon 
neighboring  parts,  so  as  to  produce  secondary  derangements. 
Thus,  pressure  upon  the  nerves  may  cause  cramps  in  the  legs. 
Compression  of  the  large  venous  trunks  may  give  rise  to  oedema 
of  the  lower  limbs  and  dilatation  of  the  abdominal  veins.  If  this 
venous  dilatation  be  very  marked,  the  superficial  veins  being  seen 
to  ramify  upon  the  abdominal  wall,  and  to  join  the  veins  of  the 
chest-walls,  tabes  should  always  be  suspected  in  the  absence  of 
chronic  peritonitis  or  enlargement  of  the  liver. 

Ascites  is  not  necessarily  a  result  of  the  tuberculization  of  these 
glands,  and  is  rarely  produced  by  direct  pressure  unless  the  portal 
vein  is  compressed  by  enlargement  of  the  glands  occupying  the 
hepatic  notch.  It  may,  however,  be  produced  in  a  different  way : 
thus,  friction  of  the  enlarged  glands  against  the  peritoneum  lining 
the  abdominal  wall  may  cause  inflammation  of  that  membrane. 
In  these  cases   there  is  some  fever,  with   increase  of  abdominal 

'  Lecture  on  Tuberculosis.     Medical  Times  and  Gazette,  Oct.  18G1. 


MESENTERIC    PHTHISIS  —  DIAGNOSIS.  233 

tenderness  and  colicky  pains.  The  belly  becomes  tense  from 
gaseous  distension  of  the  intestines;  and  indistinct  fluctuation  is 
often  felt  from  adhesion  of  the  bowels  one  to  another,  with  the 
addition  of  a  little  serous  effusion  between  the  coils.  Vomiting  is 
not  constant,  and  diarrhoea,  if  previously  present,  is  not  interfered 
with.  The  amount  of  ascites  is  in  these  cases  not  very  great,  and  the 
sj'mptoms  of  peritonitis  generally  are  far  from  being  well  marked. 

Adhesion  may  take  place  between  an  enlarged  mesenteric  gland 
and  a  coil  of  intestines :  when  the  gland  softens,  perforation  of  the 
bowel  may  result. 

The  course  of  the  disease  is  slow,  but  its  duration  is  difficult  to 
estimate,  on  account  of  the  obscurity  of  the  earlier  symptoms.  It 
seems  to  occur  more  frequently  in  boys  than  in  girls,  and  is  seldom 
found  in  children  under  three  years  of  age :  most  commonly 
between  the  fifth  and  the  tenth  years.  The  children  do  not  neces- 
sarily die ;  they  sometimes  recover. 

Diagnosis.  —  The  diagnosis  of  tabes  mesenterica  can  only  be 
made  satisfactorily  by  the  sense  of  touch.  If  we  can  hold  the  mass 
between  the  finger  and  thumb,  proof  of  its  presence  is  indisputable, 
and  this  proof  is  the  only  one  which  leaves  no  doubt  upon  the 
mind.  Enlargement  of  the  belly  is  no  evidence  of  the  glandular 
disease,  for  flatulent  distension  is  in  children  a  common  accompani- 
ment of  ill  health,  and  in  tabes  the  abdominal  wall  is  more  often 
retracted  than  expanded.  Wasting,  again,  is  found  in  almost  all 
chronic  diseases  tubercular  or  otherwise  ;  and  diarrhoea  is  a  symp- 
tom by  no  means  confined  to  tabes.  These  symptoms  may  be 
present,  but  they  are  not  a  result  of  the  tubercular  lesion  of  the 
glands,  and  either  alone  or  combined  are  useless  as  indications  of 
the^disorder  under  consideration. 

If,  as  has  been  said,  the  superficial  veins  are  distinctly  seen  to 
ramify  on  the  abdominal  wall,  and  to  join  similiar  veins  on  the 
thoracic  parietes,  tabes  should  be  suspected,  but  nothing  more  than 
suspicion  is  allowed  by  such  evidence.  Any  interference  with  the 
portal  circulation  will  produce  the  same  result,  and  when  the  abdo- 
minal wall  is  tense  it  is  difficult  to  exclude  hepatic  disease. 

Even  when  by  direct  exploration  the  existence  of  a  tumor  in 
the  belly  has  been  ascertained,  we  have  still  to  satisfy  ourselves 
that  the  tumor  is  formed  by  enlarged  mesenteric  glands.  The 
disease  may  be  simulated  by  fecal  accumulation  in  the  colon,  or 
by  tubercular  masses  attached  to  the  omentum. 


234  TUBERCULIZATION    OF    GLANDS. 

Fecal  accumulations  are  distinguished  by  the  absence  of  tender- 
ness; by  the  situation  of  the  tumor,  which  usually  occupies  the 
transverse  or  descending  colon  instead  of  the  umbilical  region ; 
and  by  the  shape  of  the  mass  which  is  elongated,  the  long  axis 
being  in  the  direction  of  the  long  axis  of  the  bowel  in  which  it 
is  contained.  In  doubtful  cases,  a  positive  opinion  should  be  re- 
served until  the  effect  upon  the  swelling  of  a  good  injection  has 
been  tried.  For  a  child  of  four  years  old,  an  enema^  of  a  pint  or 
more  of  soap  and  water,  or  thin  gruel,  containing  half  an  ounce  of 
oil  of  turpentine  and  four  ounces  of  olive  oil,  should  be  thrown  up 
the  bowel  by  a  good  syringe.  The  injection  should  be  retained 
for  a  few  minutes  by  firm  pressure  upon  the  anus,  and  then  be 
allowed  to  escape.  If  the  tumor  is  due  to  fecal  accumulation, 
a  quantity  of  pale,  brittle  lumps  will  be  discharged  with  the  re- 
turning fluid,  and  the  swelling  previously  noticed  in  the  belly  will 
be  found  to  have  disappeared.  If  tuberculized  glands  are  the 
cause  of  the  tumor,  the  evacuation  of  gas  and  fecal  matter  will 
only  make  the  presence  of  the  enlargement  more  manifest,  by  re- 
moving the  tension  of  the  abdominal  wall,  and  allowing  of  more 
efficient  exploration  of  the  cavity  of  the  belly.  In  these  cases  an 
enema  of  sufficient  quantity  to  distend  the  bowel  is  of  more  value 
than  any  number  of  aperients.  It  is  well,  also,  to  remember  that 
fecal  accumulation  having  once  occurred,  there  is  great  liability 
to  a  second  collection  of  the  same  kind,  therefore  for  some  time 
afterwards  a  careful  watch  should  be  kept  over  the  condition  of 
the  bowels. 

Between  tubercular  masses  attached  to  the  omentum  and  tuber- 
cular mesenteric  glands  the  distinction  is  often  very  difficult,  par- 
ticularly if  the  seat  of  the  tumor  happens  to  be  the  umbilical 
region.  When  their  seat  is  the  omentum  the  masses  are  more 
superficial,  are  less  nodular,  and  have  better  defined  edges  than  is 
the  case  where  the  glands  themselves  are  diseased.  They  are 
usually  also  more  freely  movable. 

In  a  case  mentioned  by  MM.  Eilliet  and  Barthez,''  a  cancerous 
pancreas  offered  some  resemblance  to  the  tumor  of  tabes  mesente- 
rica,  but  was  distinguished,  amongst  other  signs,  by  the  presence 
of  vomiting,  jaundice,  and  abdominal  pains. 

'  Jenner  on  Tuberculosis,  Meiiical  Times  and  Gazette,  Oct.  1861. 
*  Maladies  des  Enfauts,  vol.  iii.  p.  817. 


ANATOMICAL    CHARACTERS,  235 

Anatomical  characters  of  enlarged  tubercular  glands. — The  forma- 
tion of  tubercle  usually  begins  in  the  centre  of  the  gland,  and 
from  this  point  the  morbid  change  spreads  gradually  towards  the 
circumference.  Occasionally,  however,  several  distinct  points  of 
tubercle  are  seen  at  different  parts  of  the  same  gland  ;  these  may 
increase  in  size,  and  approach  one  another  until  the  whole  gland  is 
converted  into  tubercular  matter.  The  color  of  the  diseased 
gland  is  usually  yellow,  but  sometimes  a  gray  point  is-seen  in  the 
centre,  surrounded  on  every  side  by  the  yellow  mass. 

The  glands  are  not  all  equally  affected.  Some  remain  perfectly 
healthy  while  others  are  diseased  ;  some  which  are  diseased  remain 
small,  while  others  undergo-  considerable  enlargement. 

The  alteration  in  these  glands  consists,  according  to  Yirchow,* 
in  a  great  increase  of  their  cell  elements,  with  not  unfrequently 
hypertrophy  of  the  connective  tissue.  The  cells  become  large, 
round,  tough,  transparent,  finely  granular,  and  contain  one  or  two 
large  nuclei.  They  have  a  great  tendency  to  undergo  degeneration 
by  fatty  change.  A  gland  so  altered  is  seen  at  first  as  a  large 
spongy-feeling  body ;  its  color  is  reddish,  passing,  where  the  fat 
change  is  much  advanced,  into  a  dirty,  opaque-white  color.  If 
there  is  much  hypertrophy  of  the  connective  tissue  the  gland  be- 
comes very  hard.  After  a  time  the  whole  gland  becomes  thick, 
tough,  anaemic-looking,  and  dry,  quickly  transforming  into  a  yellow, 
opaque,  cheesy  mass. 

The  capsular  vessels  become  much  enlarged,  and  the  capsule 
itself  thicker  and  divisible  into  two  layers. 

After  a  time  the  glands  soften ;  the  softening  process  usually 
begins  at  the  centre,  although  isolated  points  at  the  circumference 
may  first  undergo  this  change.  These,  on  section  of  the  gland,  are 
sometimes  seen  to  be  connected  by  prolongations  of  softening  with 
the  softened  centre.  Evacuation  of  the  liquefied  matter  may 
eventually  take  place,  a  communication  being  formed  with  some 
neighboring  organ. 

The  tubercle  sometimes  becomes  cretaceous,  as  it  does  in  other 
organs. 

In  bronchial  phthisis  the  glands  lying  at  the  bifurcation  of  the 
trachea  are  usually  the  most  enlarged.     Those  accompanying   the 

'  See  Gulstonian  Lectures  on  the  Nature  aud  Affiuities  of  Tubercle,  by  Regiuald 
Southey,  M.  D.  Oxon.     London,  18(37. 


236        •  TUBERCULIZATION    OF    GLANDS. 

bronchial  tubes  into  the  interior  of  the  lung  are  less  increased  in 
size,  although  thej  may  be  seen  larger  than  natural  as  far  as  the 
third  or  fourth  division  of  the  bronchial  tubes.  A  mass  formed 
of  these  enlarged  glands  nnay  occupy  the  anterior  mediastinum, 
extending  from  the  base  of  the  heart  to  the  top  of  the  sternum. 

In  mesenteric  phthisis  the  glands  often  unite  to  form  an  irregu- 
lar nodular  mass  as  large  as  the  fist,  or  even  larger.  The  mass  is 
situated  in  front  of  the  vertebral  column.  If  the  mesentery  is 
involved,  the  tumor  is  fixed ;  if  the  mesentery  is  free,  the  mass 
can  be  moved  a  little  to  one  side  or  the  other. 

Treatment. — On  account  of  the  readiness  with  which  the  lymph- 
atic glands,  both  internal  and  external,  become  enlarged  in  tuber- 
culous and  scrofulous  children,  it  is  of  great  importance  to  remove 
as  quickly  as  possible  any  local  irritations,  the  continuance  of 
which  would  lead  to  the  glandular  disease.  All  purulent  dis- 
charges, skin  eruptions,  and  ulcerations  of  the  skin  and  mucous 
membranes  must  therefore  receive  prompt  attention.  "Little 
colds"  must  not  be  neglected,  as  disease  of  the  bronchial  glands  is 
produced  by  pulmonary  irritation  ;  and  the  danger  of  tubercular 
enlargement  of  the  glands  of  the  mesentar}^  is  an  additional  reason 
for  keeping  a  careful  watch  over  the  condition  of  the  stomach  and 
bowels. 

In  bronchial  and  mesenteric  phthisis  the  general  measures  to  be 
employed  are  the  same  as  those  already  recommended  for  the 
treatment  of  tuberculosis.  Cod-liver  oil  is  said  to  be  of  especial 
value  in  these  cases,  and  should  be  given  with  the  precautions 
previously  enjoined.  In  the  case  of  bronchial  phthisis,  counter- 
irritation  should  always  be  adopted,  either  in  the  form  of  pustula- 
tion  with  croton  oil,  or,  for  children  of  six  or  seven  years  old,  by 
the  application  of  a  blister  of  the  size  of  a  two-shilling  piece, 
which  must  be  kept  open  for  some  time.  The  counter-irritant 
should  be  applied  to  the  upper  part  of  the  sternum  in  front,  and 
between  the  scapulae  behind,  alternately.  The  internal  use  of 
iodide  of  iron  is  also  strongly  advocated.  The  syrup  of  the  iodide 
may  be  made  use  of,  or  a  mixture  containing  half  a  grain  of  iodide 
of  potassium,  and  five  grains  of  potassio-tartrate  of  iron,  in  half 
an  ounce  of  distilled  water,  three  times  in  the  day.  The  quantity 
of  the  iodide  of  potassium  may  be  gradually  increased. 

For  mesenteric  phthisis,  the  ointment  of  iodide  of  lead  may  be 
rubbed  into  the  belly  twice  a  day,  and  iodide  of  iron  should  be 


TREATMENT.  •        237 

given  internally  as  recommended  above.  Should  peritonitis  occur, 
hot  linseed-meal  poultices  applied  to  the  belly,  and  opium  given 
cautiously  by  the  mouth,  form  the  best  remedies.  The  diarrhcea 
which  is  so  frequent  an  accompaniment  of  the  glandular  disease 
should  be  arrested  as  rapidly  as  possible.  For  the  treatment  oi 
this  complication  the  reader  is  referred  to  the  chapter  on  tubercu- 
losis, and  to  that  on  chronic  diarrhoea.  Small  enemata  of  warm 
starch  containing  five  or  ten  drops  of  tinct.  opii  are  very  useful  in 
these  cases.  Unfortunately,  the  diarrhcea  is,  in  many  instances, 
the  result  of  accompanying  tubercular  ulceration  of  the  bowels ; 
if  so,  all  our  efforts  will  prove  of  little  avail  in  retarding  the  fatal 
termination. 


CHAPTER    XI. 

DIET   OF   CHILDEEN   IN  HEALTH   AND   DISEASE. 

Diet  in  Health. — From  birth  to  six  months  old — From  six  to  twelve  months — 
From  twelve  to  eighteen  months — From  eighteen  months  to  two  years — After 
two  years. 

Diet  in  Disease. — In  simple  atrophy — In  chronic  diarrhoea — In  chronic  vomiting 
— In  rickets — In  mucous  disease — In  tuberculosis  and  pulmonary  phthisis. 

On  account  of  the  importance  of  the  subject  of  diet  in  relation 
to  children,  both  in  health  and  disease,  the  maintenance  of  their 
health,  and  the  treatment  of  their  several  disorders,  being  mainly 
dependent  upon  a  proper  regulation  of  their  food,  it  has  been 
thought  advisable  to  devote  a  chapter  especially  to  this  subject. 

Directions  upon  this  matter,  to  be  of  any  service  at  all,  must  be 
plain,  minute,  and  exhaustive.  Nothing  should  be  left  to  the  dis- 
cretion of  the  attendants.  The  articles  of  food,  the  quantity  to  be 
given,  the  hours  at  which  the  meals  are  to  be  taken,  and,  when 
necessary,  the  exact  method  in  which  the  food  is  to  be  prepared, 
should  be  all  accurately  stated  and  written  down,  or  mistakes  will 
almost  certainly  be  committed. 

In  the  following  pages  will  be  found  dietaries,  carefully  arranged 
and  tabulated,  suitable  to  infants  and  children,  both  in  health  and 
disease.  It  should  be  stated,  however,  that  the  quantities  given 
below  are  not  intended  to  be  invariable.  It  would  be  impossible 
to  lay  down  rules  which  would  be  found  suitable  to  all  children. 
Some  require  and  can  digest  much  more  than  others ;  the  quanti- 
ties, therefore,  must  be  adapted  in  each  particular  case  to  the  re- 
quirements and  capabilities  of  the  child.  The  amounts  of  farina- 
ceous food  ordered  can,  however,  seldom  be  exceeded  with  safety. 

Diet  in  Health. 
1.  from  birth  to  six  months  old. 
Diet  1. 
If   the  child  be  suckled,  and  the  breast-milk  be  found  in  all 
respects  suitable : — 
No  other  food. 


FROM    BIRTH    TO    SIX    MONTHS    OLD.  239 

The  child  should  take  the  breast  alternately  every  two  hours 
for  the  first  six  weeks;  afterwards,  every  three  hours,  except 
between  11  P.  M.  and  5  or  6  A.  M. 

In  cases  where  the  secretion  of  milk  is  slow  to  be  established, 
and  the  quantity  drawn  is  insufficient  to  supply  the  wants  of  the 
infant,  the  following  food  may  be  given  as  an  addition  to  the  breast- 
milk,  until  the  secretion  becomes  sufficiently  abundant: — 
One  tablespoonful  of  fresh  cream. 
Two  tablespoonfuls  of  whey. 
Two  tablespoonfuls  of  hot  water. 
This  mixture  must  be  taken  from  a  feeding-bottle. 
The  whey  is  made  fresh  in  the  house  by  adding  one  teaspoonful 
of  prepared  rennet  to  a  pint  of  new  milk.     The  coagulated  casein 
is  removed  by  straining  through  muslin. 

Diet  2. 

If  the  infant  be  brought  up  by  hand : — 

Kew  milk  and  lime-water,  in  equal  proportions. 

Three  to  four  ounces,  sweetened  with  a  teaspoonful  of  sugar  of 
milk  are  to  be  given  at  first  every  two  hours  from  a  feeding-bottle. 

The  proportions  of  milk  and  lime-water  must  be  varied  accord- 
ing to  the  age  of  the  infant. 

From  six  weeks  to  three  months  one-third  of  lime-water  may  be 
used ;  and  from  three  to  five  months  this  quantity  should  be  re- 
duced to  one-fourth. 

Diet  3. 

If  the  infant  be  partially  suckled,  the  breast-milk  being  poor  and 
scanty : — 

The  breast  must  be  given  only  twice  a  day. 

For  the  other  meals,  the  child  must  be  fed  upon  milk  and  lime- 
water  as  directed  in  Diet  2. 

Up  to  the  age  of  six  months  the  milk  should  be  warmed  by 
dipping  the  bottle  containing  it  into  hot  water.  After  the  age  of 
six  months  it  may  be  boiled  if  convenient.  New  unskimmed 
milk  should  always  be  used.  If  the  milk  has  been  previously 
skimmed,  a  teaspoonful  of  cream  must  be  added  to  each  meal. 

In  all  cases  where  the  child  is  artificially  fed,  the  utmost  atten- 
tion should  be  paid  to  the  cleanliness  of  the  feeding-bottle. 


240  DIET    IN    HEALTH. 

2.  FROM  SIX  TO  TWELVE  MONTHS  OLD. 

Five  meals  in  the  day. 

Diet  4. 

First  meal,  7  A.M. 

One  teaspoonful  of  baked  or  boiled  flour  carefully  prepared 
with  a  teacupful  of  milk. 
^Second  meal,  10.30  A.  M. 
Third  meal,  2  P.M. 

A  breakfastcupful  of  milk   alkalinized,  if  necessary,  by 
fifteen  drops  of  the  saccharated  solution  of  lime.^ 

Fourth  meal,  5.30  P.M. 
Same  as  the  first. 

Flth  meal,  11  P.M. 

Alkalinized  milk,  as  before. 

For  the  second  meal,  twice  a  week,  may  be  given  the  yelk  of 
one  egg,  beaten  up  with  a  teacupful  of  milk. 

The  method  of  preparing  boiled  flour  is  given  on  page  46. 
Chapman's  "entire  wheaten  flour"  should  always  be  used.  It  is 
much  to  be  preferred  for  children  to  the  ordinary  wheaten  flour, 
containing  as  it  does  the  phosphates  of  the  wheat,  and  the  cerealin, 
a  peculiar  body  which  changes  starchy  matters  into  dextrine.  The 
barked  flour  may  be  varied  from  time  to  time  with  the  same 
quantity  of  some  other  farinaceous  food,  or  of  Liebig's  "  food  for 
infants"  (Mellin's).^' 

If  there  be  constipation,  a  teaspoonful  of  fine  oatmeal  can  be 
used  instead. 

Diet  5, 

{For  a  Child  about  ten  months  old.) 

First  meal,  7  A.M. 

A  dessertspoonful  of  pearl-barley  jelly,  dissolved  in  a  break- 
fast cupful  of  milk,  and  sweetened  with  loaf-sugar. 

Second  meal,  10.30  A.  M. 

A  breakfast  cupful  of  milk,  alkalinized,  if  necessary,   by 
fifteen  drops  of  the  saccharated  solution  of  lime.^ 

1  The  solution  of  lime  need  only  be  used  in  cases  where  discomfort  has  been 
noticed  after  the  milk  meal. 
«  Seepage  48.  '  See  note  1. 


FROM    SIX    TO    TWELVE    MONTHS    OLD.  241 

Third  meal,  2  P.  M. 

The  yelk  of  one  egg  beaten  up  in  a  teacupful  of  milk. 
Fourth  ?nea?,  5.30  P.M. 
Same  as  the  first. 
Fifth  meal,  11  P.  M. 

Same  as  the  second. 
Pearl-barley  boiled  for  six  hours  forms,  on  cooling,  after  the 
water  has  been  strained  off",  a  jelly  which  dissolves  readily  in  warm 
milk. 

Diet  6. 

{To  alternate  with  the i^receding?) 

First  meal,  7  A.M. 

Half  a  teaspoonful  of  Cadbury's  cocoa  essence,^  boiled  for 
^       one  minute  in  a  breakfastcupful  of  milk. 

Second  meal,  10.30  A.  M. 

A   breakfastcupful  of  milk  alkalinized,  if  necessary,  by 
fifteen  drops  of  the  saccharated  solution  of  lime. 
Third  meal,  2  P.  M. 

A  teacupful  of  beef-tea"^  (half  a  pound  of  meat  to  the  pint). 

A  rusk. 
Fourth  meal,  6.30  P.  M. 

A  dessertspoonful  of  pearl-barley  jelly,  dissolved  in  a  break- 
fastcupful of  milk,  and  sweetened. 
Fifth  meal,  11  P.  M. 

Same  as  the  second. 

•  In  Cadbury's  Cocoa  two-thirds  of  the  fatty  matter  are  removed.  It  is  there- 
fore more  digestible  than  the  ordinary  cocoas,  and  far  better  adapted  for  an 
infant's  diet. 

2  Beef-tea  is  to  be  made  in  the  following  way.  Put  half  a  pound  (or  a  pound, 
according  to  the  strength  required)  of  rump-steak,  cut  up  into  small  pieces,  into 
a  covered  copper  saucepan  with  one  pint  of  cold  water.  Let  this  stand  by  the 
side  of  the  fire  for  four  or  five  hours,  and  let  it  then  simmer  gently  for  two  hours. 
Skim  well  and  serve. 

The  meat  used  should  be  as  fresh  as  possible — the  fresher  the  better — and 
should  be  cleared  beforehand  of  all  fat  or  gristle.  If  this  precaution  be  neglected, 
a  greasy  taste  is  given  to  the  beef-tea  which  cannot  be  afterwards  removed  by 
skimming.  The  saucepan  used  should  be  made  of  copper  or  tin.  Iron  saucepans 
should  not  be  used  unless  enamelled.  In  re-warming  beef-tea  which  has  been 
left  to  cool,  care  must  be  taken  to  warm  the  tea  up  to  the  point  at  which  it  is  to 
be  served,  and  no  higher.     It  should  on  no  account  be  allowed  to  boil. 

16 


242  DIET    IN    HEALTH. 

It  is  advisable,  as  a  rule,  to  avoid  giving  intermediate  meals, 
and  therefore  the  meals  should  be  made  sufficiently  large  to  satisfy 
all  reasonable  demands. 

If  the  child  requires  food  before  7  A.  M.,  on  waking  from  sleep, 
a  little  milk  may  be  given  him. 

A  healthy  child,  between  ten  and  twelve  months  old,  will  re- 
quire from  a  pint  and  a  half  to  a  quart  of  milk  in  the  twenty-four 
hours. 

3.  from  twelve  to  eighteen  months  old. 
Diet  7. 
First  meal,  7.30  A.  M. 

A  rusk,  or  a  slice  of  stale  bread,  well  soaked  in  a  break- 
fastcupful  of  new  milk. 
Second  meal,  11  A.  M.  ^ 

A  drink  of  milk ;  a  plain  biscuit  or  slice  of  thin  bread-and- 
butter. 

Third  meal,  1.30  P.  M. 

A  teacupful  of  good  beef-tea  (a  pound  of  meat  to  the  pint), 

or  of  beef-gravy,  with  rusk ; 
A  good  tablespoonful  of  light  farinaceous  puddihg. 

Fourth  meal,  6  P.  M. 

Same  as  the  first. 
Fifth  meal,  11  P.  M.  (if  required). 

A  drink  of  milk. 

Diet  8. 
{To  alternate  with  the  preceding^ 

First  meal,  7.30  A.  M. 

The  yelk  of  a  lightly-boiled  egg ; 

A  slice  of  thin  bread-and-butter ; 

A  cupful  of  new  milk. 
Second  meal,  11  A.  M. 

A  drink  of  milk  ; 

A  slice  of  thin  bread-and-butter. 
Tliird  meal,  1.30  P.  M. 

A    mealy  potato,    well    mashed  with  a  spoon,  moistened 
with  two  tablespoonfuls  of  good  beef  gravy ; 

A  cupful  of  new  milk. 


FROM    TWELVE    TO    EIGHTEEN    MONTHS    OLD.         243 

Fourth  meal,  6  P.  M. 

A  rusk,  or  slice  of  stale  bread,  well  soaked  in  a  breakfast- 
cupful  of  milk. 

Fifth  meal,  IIP.  M.  (if  required). 
A  drink  of  milk. 

The  fifth  meal  at  11  P.  M.  should  never  be  given  unnecessarily. 
The  sooner  a  child  becomes  accustomed  to  sleep  all  night  without 
food  the  better.  When,  however,  he  wakes  in  the  morning,  re- 
freshed by  his  night's  rest,  he  should  never  be  allowed  to  remain 
fasting  for  an  hour  or  more  until  his  breakfast  is  prepared.  A 
drink  of  milk,  or  a  thin  slice  of  bread-and-butter,  should  be  given 
at  once. 

Some  children  will  take  larger  quantities  than  others  at  one 
meal ;  but  if  the  meals  are  made  very  large,  their  number  must 
be  reduced  in  proportion.  Many  children  between  twelve  and 
eighteen  months  old,  will  be  found  to  do  well  upon  only  three 
meals  a  day,  as  in  the  following: — 

Diet  9. 

•     First  meal,  8  A.M. 

One  teaspoonful  of  baked  flour  ; 
One  teaspoonful  of  fine  oatmeal ; 
Three-quarters  of  a  pint  to  a  pint  of  fresh  milk ; 
A  little  white  sugar. 
Second  meal,  1  P.M. 

The  same,  with  the  addition  of  the  yelk  of  one  egg. 

Third  meal,  5  P.  M. 
Same  as  the  first. 

In  this  diet  the  baked  flour  and  the  oatmeal  are  first  beaten  up 
till  smooth,  with  four  tablespoonfuls  of  cold  water,  and  are  then 
boiled.  The  milk  and  sugar  are  then  added,  and  the  mixture  is 
boiled  till  it  thickens. 

For  the  second  meal,  the  yelk  of  Qgg  is  stirred  up  in  the  sauce- 
pan and  boiled  with  the  rest. 

If  the  child  requires  anything  early  in  the  morning,  or  at  11 
P.  M.,  he  may  take  a  drink  of  milk,  or  a  thin  slice  of  bread-and- 
butter. 

A  healthy  child  of  a  year  to  eighteen  months  old  will  usually 
take  between  two  and  three  pints  of  milk  in  the  four  and  twenty 
hours. 


244  diet  in  health. 

4.  from  eighteen  months  to  two  years  old. 

Diet  10. 

First  meal,  7.80  A.  M. 

A  breakfastcupful  of  new  milk  ; 

A  rusk  or  a  good  slice  of  stale  bread. 

Second  meal,  11  A.  M. 

A  cup  of  milk. 
Third  meal,  1.30  P.  M. 

Underdone  roast  mutton,  pounded   in  a  warm    mortar,  a 
good  tablespoonful ; 

One   well   mashed    potato   moistened    with   two  or   three 
tablespoonfuls  of  gravy. 

For  drink,  milk  and  water  or  toast- water. 
Fourth  meal,  6  P.  M. 

A  breakfastcupful  of  milk  ; 

Bread-and-butter. 

After  the  age  of  eighteen  months  it  is  well  to  omit  the  meal  at 
11  P.M.  A  healthy  child  of  eighteen  months  old  should  sleep 
from  6  P.  M.  to  6  A.  M.  without  waking. 

Diet  11. 
{For  a  child  of  the  same  age.) 

First  meal,  7.30  A.  M. 

A  breakfastcupful  of  new  milk  ; 

The  lightly-boiled  yelk  of  one  egg ; 

A  thin  slice  of  bread-and-butter. 
Second  meal,  11  A.  M. 

A  cup  of  milk 
Third  meal,  1.30  P.M. 

A  breakfastcupful  of  beef-tea  (a  pound  of  meat  to  the  pint), 
containing  a  few  well-boiled  asparagus-heads,  when  in 
season,  or  a  little  thoroughly  stewed  flower  of  broccoli ; 
A  good  tablespoonful  of  plain  custard  pudding. 
Fourth  meal,  6  P.  M. 

A  breakfastcupful  of  milk  ; 
Bread-and-butter. 
These  diets  can  be  given  on  alternate  days. 


DIET    IN    SIMPLE    ATROPHY.  245 

Between  tlie  ages  of  two  and  three  years  the  same  diets  may  be 
continued.  Meat  can,  however,  be  given  every  day,  and  a  little 
well-stewed  fruit  may  be  occasionally  added. 

The  morning  and  evening  meals  should  always  consist  princi- 
pally of  milk. 

Diet  in  Disease. 

DIET  IN  simple  ATROPHY. 

For  a  child  of  two  or  three  months  old,  brought  uj)  by  hand,  weakly 
and  emaciated,  in  ivhom  milk  with  lime-water  excites  griping 
and  flatulence,  with  occasional  attacks  of  vomiting  and  purging} 

In  these  cases  we  can  often  succeed  in  rendering  the  milk  and 
lime-water  digestible  by  adding  an  aromatic.  Thus,  to  half-a-pint 
of  cold  milk  add  a  teaspoonful  of  caraway-seeds  or  chopped 
cinnamon,  inclosed  in  a  small  muslin  bag,  and  boil  for  five 
minutes.  The  bag  is  then  withdrawn,  and  the  lime-water,  and 
milk-sugar,  are  afterwards  added  as  usual. 

If  this  do  not  succeed,  one  of  the  diets  given  below  can  be  tried. 

Diet  12. 

The  child  is  to  be  fed  every  three  hours  from  a  feeding-bottle 
with  the  following,  in  alternate  meals  : — 

1.  One  teacupful  of  Liebig's  food  for  infants  (Mellin's),  dissolved 
in  a  teacupful  of  new  milk  and  water  (equal  parts),  with  the 
addition  of  one  tablespoonful  of  cinnamon  or  dill-water. 

2.  A  teacupful  of  fresh  whey  containing  a  teaspoonful  of  cream. 
If  the  amount  of  milk  given  above  cannot  be  digested,  as  often 

happens,  the  proportion  of  water  used  to  dilute  the  milk  may  be 
increased  to  two-thirds ;  or  in  some  of  the  meals  the  milk  may  be 
altogether  omitted,  using  instead  barley-water,  or  equal  parts  of 
barley-water  and  weak  chicken-broth,  in  which  the  Liebig^s  food 
can  be  dissolved. 

In  the  above  cases  Dr.  Meigs^  recommends  the  following: — 

Diet  13. 

A  scruple  of  gelatine  (i.  e.,  a  square  inch  of  the  gelatine  cake)  is 
soaked  in  cold  water  and  is  then  boiled  for  ten  or  fifteen  minutes 

'  In  all  these  cases  a  wet-uurse  should  be  provided  if  possible. 
2  Meigs  and  Pepper  on  Diseases  of  Children.     Pliiladelphia,  1870. 


246  DIET    IN    DISEASE. 

in  half-a-pint  of  water  until  it  dissolves.  To  this,  at  the  termina- 
tion of  the  boiling,  is  added,  while  stirring,  three  ounces  of  milk, 
and  a  teaspoonful  of  arrowroot,  the  latter  having  been  previously 
mixed  into  a  paste  with  a  little  cold  water.  Lastly,  just  before  re- 
moval from  the  fire  half  an  ounce  of  cream  is  stirred  up  with  the 
rest,  and  the  whole  is  sweetened  with  loaf  sugar. 

Of  this  food  three  or  four  ounces  or  more  can  be  given  every 
two  or  three  hours  from  a  feeding-bottle. 

The  above  diets  are  suitable  to  all  infants  suffering  from  simple 
atrophy  due  to  improper  feeding.  It  will,  however,  be  necessary 
to  vary  the  quantities  somewhat  according  to  age.  Thus,  a  child 
of  six  months  old  will  usually  be  able  to  take  a  teaspoonful  of 
Liebig's  food  for  infants,  dissolved  in  milk  more  or  less  diluted  for 
each  meal. 

For  a  child  of  the  same  age.  Dr.  Meigs'  food  may  be  strength- 
ened by  increasing  the  quantity  of  milk  to  six  or  ten  ounces,  and 
of  cream  to  one  or  two  ounces. 

DIET  IN  CHRONIC  DIARRHCEA. 

For  a  child  of  twelve  months  old,  luho  can  hear  milk:  purging  not 
very  severe. 

Diet  14. 

A  teaspoonful  of  Liebig's  food  for  infants  (Mellin's)  every  three 
hours,  dissolved  alternately  in  milk  and  water  (equal  parts),  and  in 
equal  parts  of  weak  veal  broth  and  barley  water. 

If  no  milk  at  all  can  be  digested,  a  good  diet  is  the  following  : — 

Diet  15. 

First  meal,  7  A.  M. 

One  teaspoonful  of  Liebig's  food  for  infants  (Mellin's),  dissolved 
in  a  teacupful  of  veal  broth  and  barley  water  (equal  parts). 
Second  meal,  11  A.  M. 

One  tablespoonful  of  cream  in  a  teacupful  of  fresh  whey. 
Third  meal,  2  P.  M. 

The  unboiled  yelk  of  one  egg  beaten  up  with  fifteen  drops  of 
brandy,  a  tablespoonful  of  cinnamon  water,  and  a  little 
white  sugar. 
Fourth  meal,  5  P.  M. 

Six  ounces  of  beef-tea  (a  pound  to  the  pint). 


DIET    IN    CHRONIC    DIARRH(EA.  247 

Fifth  meal,  11  ^.M. 
Same  as  the  first. 

After  a  week  or  ten  days  a  little  milk  can  be  introduced  into  the 
diet,  beginning  cautiously,  and  only  once  in  the  day.  Thus,  for 
the  first  meal  milk  may  be  substituted  for  the  veal  broth  and  be 
added  to  the  barley-water  and  Liebig's  food.  If  this  be  found  to 
agree,  the  same  change  may  be  made  in  the  fifth  meal. 

Another,  consisting  partially  of  milk,  for  a  child  of  twelve 
months  old : — 

Diet  16. 
First  meal,  7  A.  M. 

One  teaspoonful  of  Cadbury's  cocoa  essence  boiled  for  one 
minute  with  a  teacupful  of  milk. 
Second  meal,  10  A.  M. 

A  teacupful  of  beef-tea  (a  pound  to  the  pint). 
Third  meal,  2  P.M. 

A  teacupful  of  milk  alkalinized  with  fifteen  drops  of  saccha- 
rated  solution  of  lime. 
Fourth  meal,  5  or  6  P.M. 

The  yelk  of  one  Qgg  beaten  up  with  brandy  and  cinnamon 
water,  as  in  Diet  16,  or  beaten  up  with  a  teacupful  of  veal 
broth  and  barley-water  (equal  parts). 
Fifth  meal,  11  P.  M. 

One  teaspoonful  of  Liebig's  food  for  infants  (Mellin's)  dissolved 
in  a  teacupful  of  warm  milk. 
If  the  child  be  much  reduced  by  the  purging,  the  diet  should  be 
simpler  in  character  and  the  meals  should  be  smaller,  more  fre- 
quently repeated,  as  in  the  following : — 

Diet  17. 
{For  a  weakly  child  of  twelve  months  old.) 

First  meal,  7  A.  M. 

Four  ounces  of  whey  with  a  teaspoonful  of  cream. 
Second  meal,  9.30  A.  M. 

Four  ounces  of  veal  broth  (half  a  pound  to  the  pint). 
Third  meal,  noon. 

A  teaspoonful  of  pearl  barley  jelly,  dissolved  in  four  ounces 
of  whey. 


248  DIET    IX    DISEASE. 

Fourth  meal,  2. SO  "P. M.. 

Four  ounces  of    milk    and  lime-water  (equal  parts)  witli  a 
tablespoonful  of  cinnamon- water. 
Fifth  meal,  5  P.  M. 

One  teaspoonful  of    Liebig's  food  for   infants  (Mellin's)  dis- 
solved in  four  ounces  of  barley-water. 
Sixth  meal,  9  P.M. 

Same  as  the  second. 
During  the  night  whey  or  barley-water  may  be  given. 
If  the  purging  be  very  severe,  all  regular  meals  should  be  dis- 
continued, and  the  child  be  supplied  with  any  of  the  above  foods 
in  quantities  of  one  tablespoonful  every  quarter  of  an  hour.  Milk, 
however,  is  seldom  found  to  agree.  Diet  13  will  often  succeed  in 
these  cases. 

DIET  IN  CHRONIC  VOMITING. 

In  this  disorder  the  food  must  be  given  in  minute  quantities, 
one  teaspoonful  in  many  cases  being  all  that  can  be  retained  at  one 
time.     This  may  be  repeated  every  ten  minutes. 

Choice  may  be  made  from  the  following: — 

Diluted  whey  with  cream,  as  in  Diet  1, 
Milk  and  lime-water  with  cinnamon-water. 
One  teaspoonful  of  Liebig's  food  for  infants  (Mellin's)  dis- 
solved in  four  ounces  of  milk  and  water  (equal  parts), 
or  in  equal  parts  of  weak  veal  broth  and  barley-water. 
Dr.  Meigs'  food.     {Diet  13.) 
Whatever  the  food  may  be,  it  should  be  given  cold  or  hot,  not 
tepid. 

If  the  vomiting  be  only  occasional  and  not  severe,  Diet  17  may 
be  tried,  suiting  the  quantities  to  be  given  at  one  time  to  the  de- 
gree of  irritability  of  the  stomach. 

\  DIET  IN  RICKETS. 

Here  the  kind  of  diet  will  depend  in  a  great  measure  upon  the 
condition  of  the  alimentary  canal.  In  almost  all  cases  it  will  be 
found  that  farinaceous  food  has  been  supplied  in  excessive  quan- 
tities, and  the  amount  will  have  to  be  considerably  reduced.  If 
the  bowels  are  relaxed,  with  loose,  slimy,  offensive  motions,  Diets 
15  and  16  will  be  suitable.     If  the  motions  are  healthy,  Diets  5,  6, 


DIET    IN    MUCOUS    DISEASE.  249 

7,  8,  10,  11,  may  be  made  use  of,  according  to  the  age  of  the 
child. 

If  the  child  be  sixteen  or  eighteen  months  old,  the  following  is 
of  service  : — 

Diet  18. 
First  meal,  7.30  A.  M. 

One  or  two  teaspoonfuls  of  Liebig's  food  for  infants  (Mel- 
lin's)  dissolved  in  a  breakfastcupful  of  milk. 
Second  meal,  11  A.  M. 

A  breakfastcupful  of  milk  alkalinized  by  fifteen  drops  of 
the  saccharated  solution  of  lime. 

Third  meal,  2  P.  M. 

A  good  tablespoonful  of  well  pounded  mutton  chop  with  gravy, 
and  a  little  crumbled  stale  bread ; 
Or,  a   good   tablespoonful  of  the   flower  of  broccoli  well 
stewed'with  gravy  until  quite  tender ; 
A  little  dry  bread  ; 
For  drink,  milk  and  water. 
Fourth  meal,  6  P.  M. 
Same  as  the  first ; 
Or  (if  no  meat  has  been  given)  the  lightly-boiled  yelk  of 

one  Qgg ; 
A  little  thin  bread-and-butter  ; 
Milk  and  water. 

DIET  IN  MUCOUS  DISEASE. 

(Farinaceous  food  is  as  much  as  possible  to  be  avoided.) 

Diet  19. 

{For  a  Child  about  seven  years  of  age  and  upwards) 

Breakfast,  8  A.  M. 

Three-quarters  of  a  pint  of  fresh  milk  alkalinized  by  twenty 

drops  of  the  saccharated  solution  of  lime; 
A  thin  slice  of  well-toasted  bread. 
Dinner,  12. 

A  small  mutton  chop  without  fat,  broiled ; 
A  little  well-boiled  spinach  or  French  beans,  according  to 
season : 


250  DIET    IN    DISEASE. 

A  thin  slice  of  well-toasted  bread ; 

Half  a  wineglassful  to  a  wineglassful  of  sound  sherry,  diluted 
with  twice  its  bulk  of  water. 
Tea,  4  P.  M. 

Same  as  breakfast. 
Supper,  7  P.  M. 

A  breakfastcupful  of  beef- tea  (a  pound  to  the  pint). 

Diet  20. 

{For  the  same) 
Breakfast,  8  A.  M. 

Half-a-pint  of  new  milk,  alkalinized  with  fifteen  drops  of  the 
saccharated  solution  of  lime ; 

A  thin  slice  of  cold  roast  beef  or  mutton ; 

A  thin  slice  of  well-toasted  bread. 
Dinner,  12. 

A  little  boiled  sole  or  turbot  (without  melted  butter). 

A  thin  slice  of  stale  bread. 

A  large  wineglassful  of  claret,  diluted  with  an  equal  bulk  of 
water. 
Tea,  4  P.  M. 

A  poached  egg  on  a  thin  slice  of  dry  toast. 

Milk  and  water. 
Supper,  7  P.  M. 

Three-quarters  of  a  pint  of  alkalinized  new  milk. 

Diet  21. 
{For  the  same) 
Breakfast,  8  A.  M. 

One  teaspoonful  of  Oadbury's  cocoa  essence  boiled  for  one 

minute  in  half  a  pint  of  milk; 
A  slice  of  thin  dry  toast. 
Dinner,  12. 

The  wing  of  a  roasted  or  boiled  fowl ; 

A  little  well-boiled  flower  of  cauliflower,  or  well-stewed  celery ; 

A  slice  of  thin  dry  toast  or  stale  bread ; 

A  claretglassful  of  ligrht  bitter  ale. 


DIET    IN    TUBERCULOSIS    AND    PHTHISIS.  251 

rea,4:F.M. 

Half-a-pint  of  alkalinized  milk; 
A  lightly  boiled  egg ; 
A  slice  of  thin  dry  toast. 

Supper,  7  P.  M. 

A  breakfastcupful  of  beef  tea  (a  pound  to  the  pint); 
A  thin  slice  of  dry  toast. 

It  would  be  unnecessary  to  occupy  space  by  giving  more  diets 
of  the  same  kind.  The  above  will  serve  as  illustrations  of  the 
kind  of  food  to  be  recommended. 

Two  of  the  meals  should  always  consist  of  milk.     For  the 
other  meals  selection  should  be  made  from  the  followinor : — 

Meats: — Eoast  beef;  roast  or  boiled  mutton;  roast  or  boiled 
fowl  (without  sauces) ;  roasted  pheasant,  turkey,  lark,  snipe. 

No  spiced  or  salted  or  preserved  meats  can  be  allowed. 

Fish: — Boiled  cod,  turbot,  mackerel,  or  sole;  raw  oysters. 

Eggs : — Boiled  or  poached. 

Soup  : — Clear  turtle ;  beef  or  veal  tea. 

Vegetables  : — Cauliflower ;  spinach  ;  turnip  greens ;  asparagus  ; 
young  French  beans ;  lettuce  or  celery  (stewed). 

For  drink : — Sound  sherry  or  claret  (not  burgundy),  diluted 
with  water;  light  bitter  ale;  toast-water;  milk  and  water. 

DIET  IN  TUBERCULOSIS  AND  PULMONARY  PHTHISIS. 

In  these  diseases  farinaceous  food,  and  indeed  all  fat-forming 
material,  is  of  value ;  but  usually  the  capability  of  digesting  such 
food  is  not  very  great,  as  in  almost  all  such  cases  there  is  a  ten- 
dency to  acid  dyspepsia.  In  arranging  the  diet,  therefore,  the 
greatest  attention  must  be  paid  to  the  capabilities  of  the  child,  so 
that  no  more  be  given  him  than  he  is  able  readily  to  digest. 

Diet  22. 
(For  a  Child  of  seven  years  and  up)wards) 

Breakfast,  ^  AM. 

Half-a-pint  of  new  milk  alkalinized  with  fifteen  drops  of 

the  saccharated  solution  of  lirne ; 
A  lightly  boiled  egg ; 
Thin  bread  and  butter. 


252  DIET    IN    DISEASE. 

Dinner,  12  or  1  P.  M. 

A  slice  of  roast  beef  or  mutton  with  gravy ; 

A  mealy  potato  well  mashed  ; 

Milky  farinaceous  pudding ; 

For  drink,  half  a  wineglassful  of  dry  sherry,  diluted  with 

twice  its  bulk  of  water.        , 
Tea,  4  or  5  P.  M. 

A  teaspoonful  of  chocolate  or  cocoa  boiled  with  half-a-pint 

of  milk ; 
Thin  bread-and-butter,  or  a  rusk. 

Supper,  7  or  8  P.  M. 

Half-a-dozen  raw  oysters ; 
Bread-and-butter. 
The  ordinary  cocoa  is  to  be  preferred  for  the  third  meal,  if  it 
can  be  digested.     If  it  seem  too  heavy,  Cadbury's  cocoa  essence 
may  be  used  in  stead. 

Diet  23. 
{For  a  Child  of  the  same  age) 

BreaTcfast,  8  A.M. 

Alkalinized  new  milk,  as  much  as  desired ; 

A  rusk,  or  bread-and-butter. 
Dinner,  12  or  1  P.  M. 

A  slice  of  boiled  leg  of  mutton ; 

A  well-boiled  carrot  or  turnip; 

A  spoonful  of  savory  omelet ; 

For  drink,  dry  sherry  and  water,  as  before. 
Tea,  4  or  5  P.  M. 

Bread  and  milk. 
Su'pim;  7  or  8  P.  M. 

A  small  basin  of  tapioca  soup,  or  of  clear  turtle  soup. 

Diet  24. 

{For  the  same  age.) 

Breakfast,^  AM. 

Bread  and  milk;  or,  cocoa  and  milk,  as  in  Diet  22. 

Dinner,  12  or  1  P.  M. 

Koast  or  boiled  fowl ; 


DIET    IN    TUBERCULOSIS    AND    PHTHISIS.  253 

A  mealy  potato ; 

Sherry  and  water ; 

For  dessert,  a  good  buncli  of  sweet  grapes. 
Tea,  4  or  5  P.  M. 

A  liglitly-boiled  Q^g ; 

Thin  bread-and-butter : 

Half-a-pint  of  milk ; 

Or,  the  egg  may  be  beaten  up  raw  with  the  milk. 
Supper,  7  or  8  P.  M.    ' 

A  basin  of  stronor  beef-tea. 


OBEX. 


ABDOMEN,  in  mesenteric  phthisis,  231 
large  in  infants,  22 

cause  of,  in  rickets,  108 
Abdominal  bandage,  52,  73,  75 
disease,  cvy  in,  22 
muscles  motionless  in  respiration,  22 
pain  may  prevent  sucking,  51 
Abundant  secretion  of  breast-milk,  30 
Accumulation  offlatus,  causing  big  belly, 
23 
fecal  matter,  23 

may  be  mistaken  for  enlarged 
mesenteric  glands,  233 
Acidity,  treatment  of,  56 
Acute  diarrhoea,  39 

treatment  of,  56 
in  rickets,  131 
in  inherited  syphilis,  153 
diseases,  dangers  of,  18 

secondary,  18 
indigestion,  39 

treatment  of,  59 
Admission  into  body  of  acaris  lumbri- 

coides,  172 
Advantage   of    putting    child   early   to 

breast,  41,  42 
Age  of  milk  of  importance  in  choosing 

wet-nurse,  42 
Air,  change  of,  in  mucous  disease,  168 
rickets,  128 
tuberculosis,  197 
Albuminates,  their  value  in  nutrition,  32 
Albuminoid  degeneration  in  rickets,  123 
Alcohol  in  mucous  disease,  163 
Alkalies,  their  value  in  artificial  feeding, 
44 
in  chronic  tuberculosis,  201 
in  mucous  disease,  164 
Alkaline   sprays  for  unabsorbed  pneu- 
monic deposit,  225 
Aloes  in  chronic  vomiting,  92 

mucous  disease,  165 
Alum  in  mucous  disease,  167 
Analysis  of  bone  in  rickets,  117 
Anatomical  characters  of  chronic  diar- 
rhoea, 69 
of  enlarged  tubercular  glands, 
235 


Anatomical  characters — 

of  pulmonary  phthisis,  210 
of  rickets,  114 
of  tubercle,  185 
Ani,  prolapsus,  treatment  of.  182 
Aphthje,  39 

difficulty  of  sucking  from,  51 
treatment  of,  58 
Appearance  of  a  rickety  child,  109 
tongue  in  mucous  disease,  157 
Aperients  for  infants,  53 
Appetite  in  chronic  diarrhoea,  62 
wasting  children,  37 
to  improve,  in  chronic  tuberculosis, 
200 
Applications,  external,  24 
Areolar   fragments  of  elastic  tissue  'in 

sputum,  219 
Aromatics,  value  of,  for  infants,  55,  81 
Arrest  of  growth  of  bone  in  rickets,  105 
Articulations  in  rickets,  106 
Artificial  feeding,  44 
Ascaris  lumbricoides,  170 

admission  of,  into  body,  172 
description  of,  170 
migrations  of,  172 
symptoms  of  176 
treatment  of,  180 
Ascites,  a  cause  of  big  belly  in  infants, 
22 
in  tabes  mesenterica,  232 
Ass's  milk,  44,  90 
Asthmatic  seizures  in  bronchial  phthisis, 

229 
Astringents  for  chronic  diarrhoea,  81 
Astringent  sprays  for  pulmonary  phthi- 
sis, 225 
Atrophia    lactantium.      See    Diarrhoea, 

chronic. 
Atrophy,  simple,  from  insufficient  nour- 
ishment, 29 
Auscultation  of  chest  in  infants,  207 
Auscultatory  signs  in  bronchial  phthisis, 
229 
of  chronic  pulmonary  phthisis, 

207 
of  fibroid  phthisis,  218 
of  scrofulous  pneumonia,  216 


256 


INDEX. 


BAKED  flour,  mode  of  preparation,  77 
Sandage,  elastic,  to  loose  joints  in 
rickets,  130 
Bandage,  flannel,  to  belly,  52,  73,  75 
Baths,  cold,  27 

danger  of,  in  phthisis,  223 
hot,  26 

mercurial,  150 
mustard,  26 

warm,  for  constipation,  54 
colic,  57 
convulsions,  58 
Belly,  large,  in  rickets,  108 
Bending  of  ribs  in  rickets,  102 
Big  belly,  causes  of,  22 
Bilious  attacks  in  mucous  disease,  158 
Bismuth  in  acute  indigestion,  59 

in  chronic  diarrhoea,  81 
Blisters  for  bronchial  phthisis,  236 

inadmissible  for  infants,  26 
Blood,  expectoration  of,  by  infants,  228 

in  stools,  62 
Blowing  breathing,  value  of,  208 
Boiled  flour,  46 

Bone,  analysis  of,  in  rickets,  117 
caries  of,  197 
deformities  in  rickets,  98 
in  rickets,  ossification  of,  114 
Bones,  flat,  in  rickets,  morbid  changes 
in, 115 
.     of  face,  arrest  of  development  of,  99 
reconsolidation  of,  in  rickets,  116 
Bothriocephalus  latus,  171 
Brain,  enlargement  of,  in  rickets,  120 
Breathing,  harsh,  in  pulmonary  phthisis, 
209 
importance  of  watching,  in  infants, 

22 
in  bronchial  phthisis,  229 
in  pulmonary  phthisis,  208 
in  rickets,  108,  113 
weak,  in  pulmonary  phthisis,  209 
Breast,  pigeon,  in  rickets,  101 

tuberculosis,  189 
Bridge  of   nose   flattened   in    inherited 

syphilis,  135,  142 
Bronchi,  dilated,  diagnosis  of,  219 
Bronchial  breathing,  value  of,  209 
phthisis,  227 

anatomical  characters  of,  235 
alterations  of  voice  in,  228 
asthmatic  seizures  in,  229 
auscultatory  signs  of,  229 
blisters  in,  236 
cough  in,  228 
diagnosis  of,  230 
engorgement  of  veins  in,  228 
epistaxis  in,  228 
hsemoptysis  in,  228 
hoarse  voice  in,  229 
laryngismus  stridulus  in,  229 
pressure  on  nerves  in,  228^ 


Bronchial  phthisis — 

pressure  on  trachea  in,  229 

pressure  on  veins  in,  228 

rupture  of  vessels  in,  228 

symptoms  of,  228 

termination  of,  230 

treatment  of,  236 

venous  hum  in,  230 
Bronchitis,  difficulty  of  sucking  in,  51 
in  rickets,  110 

treatment  of,  131 
Butter,  excess  of,  in  milk,  30 
Buttocks,  eruption  on,  in  inherited  sy- 
philis, 136 


CAFE-AU-LAIT  tint  of  face,  in  inhe- 
rited syphilis,  137 
Calomel  in  chronic  vomiting,  92. 
inherited  syphilis,  149,  154 
Capsicum,  tincture  of,  in  chronic  diar- 
rhea, 82. 
Care  required  during  dentition,  74 
Caries  of  bone,  early  removal  of,  197 
Carpo-pedal  contractions  in  rickets.  111 
Casein  of  cow's  milk,  coagulability  of, 

33,  44. 
Catarrh  in  rickets,  110 
danger  of,  123 
treatment  of,  131 
Causes  of  chronic  diarrhoea,  66 

pulmonary  phthisis,  221 
tuberculosis,  193 
vomiting,  88 
large  belly  in  infants,  22 
mucous  disease,  159 
refusal  of  breast  by  infants,  51. 
rickets,  123 
simple  atrophy,  29 
Cavernous  breathing,  value  of,  209 
Cavities  in  lung,  anatomical  characters 
of,  212 
cicatrization  of,  213 
diagnosis  of,  218 
Cerebral  aflections,  cry  in,  22 
sinuses,  thrombosis  of,  63 
Cestode  worms,  169,  171 
Change  of  air  in  pulmonary  phthisis, 
223 
in  mucous  disease,  168 
rickets,  128 
tuberculosis,  197 
Changes,  morbid,  in  flat  bones  in  rickets, 

115. 
Characters,  anatomical,  of  chronic  diar- 
rhoea, 69. 
of  enlarged  tubercular  glands, 

235 
of  pulmonary  phthisis,  210 
of  rickets,  114 
of  tubercle,  185 
Chest,  deformities  of,  in  rickets,  101 


INDEX. 


257 


Chest- 
examination  of,  in  infants,  206 
expander,  the,  199 
shape  of,  in  tuberculosis,  189 
Chronic  diarrhoea.      See  Diarrhcea. 
hydrocephalus  in  rickets,  112 
interstitial  keratitis,  140 
pulmonary  phthisis.     See  Phthisis. 
tuberculosis.      See  Tuberculosis, 
vomiting.     See  Vomitiiuj. 
Cicatrices,  linear,  in  inherited  syphilis, 

137 
Cicatrization  of  cavities   in    the   lung, 

213 
Cirrhosis  of  lung,  a  form  of,  213 
Clavicle,  deformity  of,  in  rickets,  103 
Cleanliness  of  feeding  bottle,  importance 

of,  45,  48,  55. 
Cleft  palate,  an  obstacle  to  sucking,  51 
feeding  bottle  for  cases  of,  51 
Climate,  change  of,  in  mucous  disease, 
168 
in  pulmonary  phthisis,  223 
in  rickets,  128 
in  tuberculosis,  197 
Coagulabilityof  casein  of  human  milk,  33 
Consolidation  of  bone  in  recovery  from 
rickets,  116 
of  lung,  chronic,  rare  in  infants,  204 
Conduction  of  laryngeal  sounds  to  chest, 

208 
Constipation  in  infants,  cause  of,  36. 
enemata  for,  54 
treatment  of,  53 
warm  bath  for,  54 
in  mucous  disease,  159 
Contraction  of  brows  in  infants,  20 
Convulsions,   reflex,    iufrequency  of   in 
wasted  children,  20 
from  indigestion,  39 
treatment  of,  58 
from  worms,  176 
in  rickets.  111. 

treatment  of,  132 
Corrosive  sublimate  in  inherited  syphi- 
lis, 149. 
Coryza,  syphilitic,  134 
Cough  in  bronchial  phthisis,  228 
pulmonary  phthisis,  204 
worms,  174 
Counter-irritants,  26 

in  bronchial  phthisis,  236 
in  chronic  diarrhcea,  79 
in  pulmonary  phthisis,  225 
precautions  in  using,  26 
Cowhage  for  worms,  180 
Cow's  milk,  iudigestibiiity  of,  47,  57 
Crackpot  percussion  note,  229 
Cracks  on    skin   in   inherited   syphilis, 

135 
Cramps  of  legs   in   tabes  mesenterica, 
232 

17 


Cranio  tabes,  100,  117 
Cream  in  artificial  feeding,  45,  48 
Cretaceous  change  in  tubercle,  187 
Croton  oil  as  a  counter-irritant,  225 
Cry  in  inherited  syphilis,  138 
infants,  characters  of,  22 
Curvature  of  spine  in  rickets,  100 
Cysticercus  cellulose,  173 


DAMP,  danger  of,  to  children,  74 
Danger  of  bronchitis  in  rickets,  123 
damp  to  children,  74 
rickets  after  chronic  diarrhcea,  85 
of    vomiting    and  diarrhoea    in    in- 
herited syphilis,  138 
Death  in  rickets  from  intensity  of  gene- 
ral disease,  112 
mode  of,  in  bronchial  phthisis,  230 
in  pulmonary  phthisis,  205 
Debility  of  stomach  a  cause  of  vomitin?, 
94  ^ 

Decay  of  teeth  in  rickets,  100 
Deep  inspirations  in    the    treatment  of 

phthisis,  222 
Deficiency  of  butter  in  milk  of  syphilitic 

mothers,  151 
Deformities  of  bone  in  rickets,  98 
chest,  101 
clavicle,  103. 
femur,  104 
humerus,  103 
pelvis,  103 
radius  and  ulna,  103 
scapula,  103 
skull,  99 
spine,  100 
tibia,  104 
Delayed  symptoms  of  inherited  svphilis, 

140 
Demeanor  of  a  rickety  child,  109 
Dentition,  care  required  during,  74 
in  chronic  diarrhoea,  Hi) 
in  inherited  syphilis,  138 
in  rickets,  100 
in  tuberculosis,  187 
progress  of,  no  guide  to  weaning,  49 
Derangement,    digestive,  accompanying 
worms,  174 
in  mucous  disease,  158, 159. 
in  rickets,  107 

treatment  of,  127 
Description  of  worms,  169 
Development  of  taenia  solium,  171 
Diagnosis    between    rickety   skull    and 
hydrocephalus,  99 
of  bronchial  phthisis,  230 
chronic  diarrhoea,  70 
fibroid  phthisis,  218 
inherited  syphilis,  141 
mucous  disease,  161 
pulmonary  phthisis,  214 


258 


INDEX. 


Diagnosis — 

rick«ts,  120 

scriit'iilous  pneumonia,  21G 
tabwi  luesenteiica,  233 
tnliercle  of  lung,  214 
tubercnlosis,  191 
vomiting,  89 
worms,  177 
Diarrhoea,  acute,  39 

treatment  of,  58 

danger  of  in  inherited  syphilis, 

138, 146 
in  rickets,  111 

treatment  of,  131 
clironic,  60 

abdominal  pain,  in,  62 

anatomical  characters  of,  69 

appearance  of  tears  in,  65,  72 

appetite  in,  62 

astringents  in,  81 

bad  feeding  a  cause  of,  66 

blood  in  stool  in,  61,  62 

causes  of,  66 

complications  of,  63 

conviulsions  in,  63 

counter-irritation  in,  79 

danger  of  rickets  after,  85 

dentition  in,  66 

diet  in,  72,  76,  246 

diagnosis  of,  70 

dry  skin  in,  61 

exanthemata  in,  63 

flannel  bandage  in,  75 

green  stools  in,  62,  72 

congestion  of  lungs  in,  63 

influence  of  dentition  on,  74 

mode  of  death  in,  64 

nitrate  of  silver  in,  82 

oedema  in,  63 

pain  in  belly  in,  62 

pneumonia  in,  63 

prevention  of,  72 

prognosis  of,  71 

secondary,  60,  68 

serous  effusions  in,  63 

stimulants  in,  83 

stools,  characteis  of  61,  62 

symptoms  of,  60 

thrombosis  of  cerebral  sinuses, 

63 
tongue  in,  62 
tonics  in,  84 
treatment  of,  75 
ulceration  of  bowels  in,  62,  69 
variations  in  intensity  of,  62 
warmtli  in  treatment  of,  75 
Diet  after  weaning,  51 

general  directions  upon,  24,  238 
in  chronic  diarrhoea,  76,  246 
pulmonary  phtiiisis,  251 
tuberculosis,  199,  251 
vomiting,  80,  248 


Diet- 
mucous  disease,  162,  249 
rickets,  127,  248 
Diets,  tabulated,  238 
Diflerences    between    gray  and    yellow 

tubercle,  186 
Dilated  bronchi,  diagnosis  of,  219 
Diminished     nervous     excitability     in 

chronic  disease,  19 
Diphtheria  a  cause  of  defective  nutrition, 

18 
Discharges  from  ears  in  scrofulous  chil- 
dren, 222 
from  nose  in  inherited  syphilis,  135 
Diseased  bone,  importance  of  early  re- 
moval of,  197 
Displacement  of  liver  and  spleen,  23, 108 
Disseminated    miliary    tubercles,    diag- 
nosis of,  214 
physical  signs  of,  209 
Drilling,  use  of  in  expanding  chest,  222 
Dulness  on  percussion   of  chest,  value 

of,  206 
Dumb-bells,  use  of,  199 
Dyspnoea  in  bronchial  phthisis,  229 


EARLY  symptoms  of  rickets,  95 
Ecthyma,  syphilitic,  136 
Effusions,  serous,  in  chronic  diarrhoea, 

63 
Elastic  bandage  to  loose  joints  in  rickets, 
130 
tissue,  fragments  of,  in  sputum,  219 
Emaciation  in  chronic  diarrhoea,  64 
tuberculosis,  190 
vomiting,  87 
mucous  disease,  157 
rickets,  108 
Emphysema  in  rickets,  118 
Empyema  with  suspected  cavity,  219 
Enemata,  astringent,  81 
for  constipation,  54 
in  diagnosis  of  fecal  accumulations, 
234 
Enlargement   of  liver   and   spleen,   23, 
lOS 
lymphatic   glands  in  rickets,   108, 

119 
lymphatic   glands    in  tuberculosis, 

226 
mesenteric  glands,  231 
spleen  in  rickets,  108,  120 
cervical  veins  in  bronchial  phthisis, 
228 
Epistaxis  in  bronchial  phthisis,  228 
Epithelial  structures,    rapid  growth  of, 

in  scrofulous  diathesis,  187 
Error,  common,  of  mothers  in  feeding  in- 
fants, 31,  34 
Eruptions  on  skin  in  inherited  syphilis, 
135 


INDEX. 


259 


Examination  of  belly  in  tabes  mesen- 
terica,  231 
of  chest  in  infants,  206 
liver,  23 
spleen,  24 

stools  in  cases  of  wastinpr,  34,  61 
Exciting  causes  of  tuberculosis,  193 
Exercise  in  chronic  tuberculosis,  198 
Exhaustion,  signs  of,  in  infants,  22 
Expectorants    in    pulmonary    phthisis, 

224 
Expectoration,  rarity  of,  in  young  chil- 
dren, 204 
Expression    of   infants,   importance    of 
noting,  20 
in  rickets,  109 
External  applications,  24 

in  chronic  diarrhoea,  79 
vomiting,  91 
Eyelids,  lividity  of,  21 


FACE,  color  of,  21 
in  inherited  syphilis,  137 
Fall  of  hair  in  inherited  syphilis,  137 
Farinaceous  foods,  46 

to  be  avoided  in  mucous   dis- 
ease, 162 
Fatality  of  bronchitis  in  rickets,  110, 123 
Fats,  their  use  in  nutrition,  32 
Feeding,  artificial,  44 
bottle,  45 

importance  of  cleanliness  of,  45, 

48,  55 
for  cleft  palate,  51 
Fecal  accumulations,  diagnosis  of,  233 
Femur,  deformities  of,  in  rickets,  104 
Fencing  useful  to  strengthen  chest,  222 
Fibroid  phthisis,  213 

diagnosis  of,  218 
physical  signs  of,  218 
prognosis  of,  220 
symptoms  of,  218 
First  suckling,  time  of,  42 
Fissures  on  skin  in  inherited  syphilis, 

137 
Fits,  inward,  38 

of  coughing  in  bronchial  phthisis, 
228 

in  pulmonary  phthisis,  204 
of  screaming  in  infants,  36 
Flannel  bandage  to  belly,  52,  73,  128 
underclothing  for  rickety  children, 
128 
Flat  bones,  morbid  changes  in,  in  rickets, 

115 
Flattened    bridge    of  nose   in    inherited 

syphilis,  135,  142 
Flatulence,  36 

treatment  of,  55 
Flatus,   accumulation   of,   causing    big 
belly,  23 


Flour,  baked,  n\ode  of  preparing,  77 

boiled,  46 
Flow  of  milk,  abundant,  42 
Fontanelle,  importance  of  noting  state  of, 
22 
in  exhaustion,  22 
in  inherited  syphilis,  138 
in  rickets,  99 

in  tubercular  children,  187 
Food,  Liebig's,  for  infants,  48,  47 

improper,  a  cause  of  chronic  diar- 
rho3a,  66 
a  cause  of  chronic  vomiting,  89 
Foods  required  for  perfect  nutrition,  32 
Freckles  as  evidence  of  tubercular  dia- 
thesis, 187 
Frequency  of  stools  in  chronic  diarrhoea, 

60,62 
Frequency  of  suckling,  43 
Fresh  air,  in  the  treatment  of  rickets, 

128 
Frictions,  24 

in  rickets  cannot  always  be  borne, 

25 
mercurial,  in  inherited  syphilis,  150 
of  use  after  cold  bath,  27 
Furrows,  M.  Jadelot's,  21 


GALVANISM  to  increase  lacteal  secre- 
tion, 41 
Genal  line,  21 

General   behavior   of  .rickety   children, 
109 
management  of  infants,  52 
Genito-crural  nerve,  stimulation  of,  19 
Glands,    bronchial,   tuberculization    of, 
227 
lymphatic,  tuberculization    of,  226 
mesenteric,  tuberculization  of,  -31 
Good  figure,  best  mode  of  forming,  196 

uur?e,  test  of,  31,  41 
Granulations,  gray,  185 

conversion  of,  into  yellow,  185 
seat  of,  in  lungs,  210 
yellow,  185 
Gray  granulations,  185 

powder  in  inherited  syphilis,  149 
Green  stools,  cause  of,  61 
Griping  from  cold  feet,  76 
pain,  treatment  of,  54 
Growth   of   bone,    arrest  of,  in    rickets 

105 
Gymnastic  exercises  in  chronic  tubercu- 
losis, 199 
in  pulmonary  phthisis,  222 


HABITUAL    constipation    in    infants, 
treatment  of,  53 
Haemoptysis  in  bronchial  phthisis,  228 
rarity  of,  in  children,  204 


260 


INDEX. 


Hair,  fall  of,  in  inlierited  syphilis,  ]37 
growth    of,  in    scrofulous    children, 
187 
Hand,  method  of  bringing  up  infants  by, 

44 
Hardening  system,  the,  196 
Harsh  respiration,  209 
Heart,  displacement  of,  in  fibroid  phthi- 
sis, 218 
Hoarse  voice  in  bronchial  phthisis,  228 
in  infants,  22 
in  inherited  syhilis,  138 
Hot  bath,  26 

in  colic,  57 
in  constipation,  54 
in  convulsions,  58 
method  of  giving,  without  ex- 
citing alarm,  26 
Humerus,  deformity  of,  in  rickets,  103 
Hunger,  sign  of,  in  infants,  43 
Hydrocephalus,  chronic,  in  rickets,  112 
spurious,  88 

treatment  of,  94 

IMPROPER   food   a   cause   of   chronic 
diarrhoea,  66 
Incontinence    of   urine   in  mucous  dis- 
ease, 157 
Increased  peristaltic  action  of  bowels,  61 
Indigestibility  of  cow's  milk,  33,  47 
Indigestion,  acute,  39 

treatment  of,  59 
Infants,  examination  of  chest  in,  206 
general  management  of.  52 
secondary  diseases  in  wasting,  18 
Infiltrated  yellow  tubercle,  210 
Influence  of  soils  on  phthisis,  196 
Inhalations  in  pulmonary  phthisis,  225 
Inherited  syphilis,  133 

appearance   of  first  symptoms, 

134 
chronic    interstitial    keratitis, 

140 
complexion  in,  137 
coryza  in,  135 
cry  in,  138 

delayed  symptoms,  140 
dentition  in,  138 
diagnosis  of,  141 
diarrhoea   in,   danger   of,   138, 

146 
diarrhoea  in,  treatment  of,  153 
diet  in,  151 

disease  of  liver  in,  139 
disease  of  spleen,  140 
disease  of  thymus  gland,  134 
ectliyma,  136 
erythema,  lo5 
fall  of  hair  in,  137 
flattened  bridge  of  nose  in,  135, 
142 


Inherited  syphilis — 

fontanelle  in,  138 
infection  after  birth,  144 
influence  of  parent  in  produc- 
ing, 142 
local  applications  in  153 
local  peritonitis  in,  140 
mercurial  inunctions  in,  150 
mercurial  baths,  150 
mucous  patches,  137 

treatment  of,  154 
necrosis  of  nasal  bones,  135 
nodes,  138 
notched  teeth,  141 
perforation  of  septum  nasi,  136 
prevention  of,  146 
prognosis  in,  145 
relapses  in,  141 
skin  eruptions  in,  135 
symptoms  of,  133 
tonics  in,  155 
treatment  of,  147 
ulcerations,  linear,  137 
vomiting  in,  139,  146 
wasting  in,  138 
Injections  in  chronic  diarrhoea,  82,  83 
Innominate  vein,  pressure  on,  in  bron- 
chial phthisis,  228 
Inoculation,  syphilitic,  by  vaccination, 

144 
Inoculability  of  tubercle,  194,  note 
Inspirations,     deep,     in     treatment     of 

phthisis,  222 
Inspissation  of  tubercle,  213 
Intellect  in  rickets,  109 
Internal  remedies,  27 
Inward  fits,  38 

Iodide  of  iron  in  inherited  syphilis,  155 
in  tuberculization  of  glands,  236 
of  lead   ointment   in  tabes  meseu- 
terica,  236 
Iron  in  chronic  tuberculosis,  202 
Irritation  of  digestive  organs  in  inherited 
syphilis,  139,  146,  149,  153 


TADELOT'S  traits,  21 
t)   Joints,  mobility  of,  in  rickets,  106 
Jugular  veins,  distension  of,  in  bronchial 
phthisis,  228 


KERATITIS,  chronic  interstitial,  140 
Kcilliker's   views   on   ossification  of 
rickety  bone,  115 


LABIAL  line,  21 
Large  belly  in  rickets,  causes  of,  108 
in  weakly  children,  causes  of, 
23 


IXDEX, 


261 


Laryngeal    sounds,    conduction    of,    to 

chest,  209 
Laryngismus     stridulus     in     bronchial 
phthisis,  229 
in  inherited  syphilis,  138 
in  rickets,  111 

treatment  of,  132 
Laryngitis,  cry  in,  22 
Late  talking  iii  rickets,  109 
walking  in  rickets,  121 
Lateral  curvature  of  spine  in  rickets,  101 
Liebig's  food  for  infants,  48,  77 
in  chronic  diarrhoea,  76 
vomiting,  90 
Ligaments,  relation  of,  in  rickets,  106 
Lime,  saecharated  solution  of,  199 
Lime-water,  to  dilute  cow's  milk,  44 
Linear  cicatrices,  137,  142 

ulcerations  in  inherited  syphilis,  137 
Liniment  for  habitual  constipation,  53 
Lips,  lividit}'  of,  21 
Lithotomy  in  rickety  children,  104,  106, 

122       ' 
Liver  disease  in  inherited  syphilis,  139 
enlarged,  a  cause  of  big  belly,  23 
enlargement  of,  in  rickets,  108 
mode  of  examining,  24 
Lividity  of  lips  and  eyelids,  21 
Local  applications  in  inherited  syphilis, 
153 
peritonitis  in  inherited  syphilis,  140 
Looseness  of  joints  in  rickets,  106 
Lung  complication  of  rickets,  110 
treatment  of,  131 
examination  of,  in  infants,  206 
Lymphatic    glands,  enlargement  of,   in 
rickets,  119 
tuberculization  of,  226 


MALFORMATION  of  permanent  teeth 
from  syphilis,  141 
Maternal  suckling,  41 
Maw's  feeding  bottle,  45 
Measles,  a  cause  of  refusal  of  breast,  51 
Meat  for  young  children,  51 

raw,  for  chronic  diarrhoea,  83 
Mechanism  of  chest  deformity,  in  rickets, 

101 
Medicated  milk  in  treatment  of  inherited 

syphilis,  148 
Mercurial  treatment  of  inherited  syphilis, 

147 
Mesenteric  disease,  infreqnency  of,  23 
phthisis.     See  Tabes  mesenterica. 
Method  of  suckling,  42 
Migration  of  worms,  175 
Milaria  in  rickets.  96 
Miliary  tubercle,  185 

disseminated,  physical  signs  of, 
209 
diagnosis  of,  214 


Milk  abundant,  behavior  of  child  when,  31 
age    of,  importance  of,  in  choosing 

wet  nurse,  42 
cow's,  sometimes   indigestible,   33, 

47 
human,  and  cow's  milk  compared, 

33 
medicated,  in  treatment  of  inherited 

syphilis,  148 
of  syphilitic  mothers,  150 
scanty,  behavior  of  child  when,  31 
to  increase  secretion  of,  41 
Miscarriage  a  common  result  of  syphilis, 

133 
Mobility  of  joints  in  rickets,  106,  121 
Moist  air  in  phthisis,  223 
MoUities  ossium,  distinction  from  rick- 
ets, 122 
Motionless  belly  in  respiration,  22 
Movement  of  nares  in  respiration,  22 
unequal,  of  two  sides  of  chest,  22 
Mucous  disease,  156 
causes,  159 
diagnosis,  161 
diet  in.  162,  249 
treatment  of,  162 
patches,  137 

treatment  of,  154 
Mucuna  prurieus,  180 
Muscles,  voluntary,  in  rickets,  120 
Mustard  bath,  27 


NARES,  movement  of,  in  respiration, 
22 
Nasal  bones,  necrosis  of,  135 
furrow,  21 

obstruction   a   cause  of    refusal   of 
breast,  51 
Necrosis   of   nasal    bones   in   inherited 

syphilis,  135 
Nematode  worms,  169 
Nervous  sensibility  diminished  in  wasted 

children,  20 
Nettlerash  a  sign  of  indigestion,  37 
Nitrate  of  silver  in  chronic  diarrhoea,  82 
Nodes  in  inherited  syphilis,  138 
Non-mercurial    treatment   of    inherited 

syphilis,  148 
Notching  of  permanent  teeth  in  inherited 

syphilis,  141 
Nurse,  a  good,  test  of,  31,  41 
Nux  vomica  in  rickets,  130 


0 


CULO-ZYaOMATIC  furrow,  21 
(Edema  of  face  in  bronchial  phthisis, 
228 
of  feet  and  hands  in  chronic  diar- 
rhoea, 63 
of  lower  limbs  in  tabes  mesenterica, 
232 


IV 


262 


INDEX. 


Oil  of  male  fern  in  treatment  of  tape- 
worm, 181 
use  of,  as  an  external  application, 
25 
Opium  in  chronic  diarrhoea,  81 
in  pulmonary  phthisis,  224 
Ossification  of  bone  in  rickets,  114 
Over-feeding  of  infants,  32,  34 
Oxidation  of  tissues  interfered  with  by 

starches,  32 
Oxyuris  vermicularis,  168 
symptoms  of,  176 
treatment  of,  179 


PAIN  indicated  by  expression  of  face  in 
infants,  20 
in  belly,  21 
in  cliest,  20 
in  head,  20 
Parasitic  stomatitis,  37 

treatment  of,  58 
Patches,  mucous,  137 
Pathology  of  pulmonary  phthisis,  210 
rickets,  114 
tuberculosis,  185 
Pelvis,  arrest  of  growth  of,  in  rickets, 
-      106 

deformity  of,  in  rickets,  103 
Percussion,  broad,  207 
Perforation   of    bowel   in   mesenteric 
phthisis,  233 
of  septum  nasi  in  inherited  syphilis, 
135 
Pericardium,  white  patch  on,  in  rickets, 

118 
Peristaltic  action  of  bowels,  increased, 

61 
Peritonitis  a  result  of  tabes  mesenterica, 
233 
local,  in  inherited  syphilis,  140 
Perspirations  in  rickets,  96 
Pertussis,  a  cause  of  mucous  disease,  160 
Perverted   ossification   of  rickety  bone, 

114 
Phthisis,    bronchial.       See     Bronchial 
phthisis. 
different  conditions  included  under 

name  of,  203 
fibroid,   anatomical    characters    of, 
213 
diagnosis  of,  218 
prognosis  of,  220 
influence  of  soils  on,  196 
mesenteric.     See  Tabes  mesenterica 
pulmonary,  202 

anatomical  characters,  210 
auscultation  of  chest,  207 
causes,  221 
diagnosis,  214 
hffinioptysis  in,  204 
pliysical  signs,  205 


Phthisis,  pulmonary — 
prognosis,  220 
symptoms,  204 
treatment,  222 
Pigeon-breast  in  rickets,  101 
in  tuberculosis,  189 
Pleurisy,  death  from,  in  inherited  syphi- 
lis, 139 
Pneumonia,  a  cause  of  refusal  of  breast, 
51 
in  chronic  diarrhoea,  63,  71 
scrofulous,  210 

anatomical  characters  of,  210 
diagnosis  of,  216 
symptoms  of,  216 
temperature  in,  216 
without  symptoms,  19 
Pneumonic   deposits   unabsorbed,  treat- 
ment of,  225 
Pneumothorax,   a  result  of    pulmonary 

phthisis,  205 
Pomegranate  bark  in  treatment  of  tape- 
worm, 181 
Pony  exercise  in  chronic  tuberculosis, 

198 
Portal  vein,  pressure  on,  232 
Potash,  chlorate  of,  for  aphthse,  58 
Precautions  against  cold,  73 
Pregnancy  of  mother  a  reason  for  wean- 
ing, 50 
Premature   weaning    sometimes    neces- 
sary, 50 
Preparations  of  mercury  in  treatment  of 

inherited  syphilis,  149 
Pressure  of  air  the  cause  of  chest  dis- 
tortion, 102,  189 
on    nerves   of    chest    by   enlarged 

bronchial  glands,  22*^ 
on  superior  vena  cava,  228 
on  trachea,  229 

on  veins  in  abdominal  cavity,  232 
Prevention  of  diarrhoea,  72 
inherited  syphilis,  146 
rickets,  126 
tuberculosis,  195 
Prognosis  in  chronic  diarrhoea,  71 
inherited  syphilis,  145 
pulmonary  phthisis,  221 
rickets,  122 
Prolapsus  ani,  treatment  of.  183 
Pulmonary  phthisis.     See  Phthisis. 
tubercle  in  infants,  209 

diagnosis  of,  214 
Purgative  enemata,  64 

for  habitual  constipation  in  infants, 
53 
Pus  in  stools. 


RADIUS   and  ulna,  deformities  of  in 
rickets,  103 
Rash,  sypliilitic,  135 


INDEX, 


263 


Raw  meat  in  treatment  of  chronic  diar- 

rlicea,  83 
Recousolidation  of  bone  in  rickets,  116 
Recovery  in  chronic  diarrhoea,  65 

in  rickets,  113 
Red-gum,  37 
Reflex  convulsions,  20 

rare  in  cachectic  children,  20 
Refusal  of  breast  by  infants,  causes  of, 

50 
Relapses  in  chronic  diarrhoea,  62 

in  inherited  syphilis,  141 
Relaxation  of  ligaments  in  rickets,  106 
Respiration,  harsh,  209 

in  bronchial  phthisis,  229 

in  pulmonary  phthisis,  208 

in  rickets,  108 

weak,  209 
Respirator,  use  of,  in  phthisis,  199 
Retraction  of  nipple  an  obstacle  to  suck- 
ling, 50 
Rickets,  95 

albuminoid  degeneration  in,  119 

analysis  of  bone,  117 

anatomical  characters,  114 

arrest  of  growth  of  bone  in,  105 

breathing  in,  108 

catarrh  and  bronchitis  in,  110 
treatment  of,  130 

causes  of,  123 

chronic  hydrocephalus  in,  112 

climate  for,  128 

collapse  of  lung  in,  110,  118 

complications  of,  109 

convulsions  in,  111 
treatment  of,  132 

danger  of,  after  chronic  diarrhoea,  85 

danger  of  bronchitis  in,  123 

deformities  of  bone  in,  97 

demeanor  of  child  in,  109 

diagnosis  of,  120 

diarrhoea  in,  111 

treatment  of,  131 

diet  in,  128,  248 

early  symptoms  of,  95 

enlargement  of  ends  of  bones  in,  97 

enlargement  of  liver  and  spleen  in, 
108 

general  symptoms  of,  107 
tenderness  in,  96 

insidious  commencement  of,  18,  95 

intellect  in,  109 

laryngismus  stridulus  in.  111 
treatment  of,  132 

lithotomy  in,  104,  106,  122 

malaria  in,  96 

mode  of  death  in,  110,  112 

morbid  changes  in  bones,  97,  113 
in  flat  bones,  115 

not  a  diathetic  disease,  123 

nux  vomica  in,  130 

ossification  of  bone  in,  114 


Rickets — 

pathology  of,  114 

pigeon-breast  in,  101 

prevention  of,  126 

prognosis  in,  122 

recovery  in,  112 

shape  of  chest  in,  101 

skull  in,  98 

softening  of  bones,  98 

splints,  use  of,  130 

sweating  in,  96 

talking  late  in,  109 

tannin  in  treatment  of,  130 

tonics,  time  of  giving,  in,  129 

treatment  of,  127 

walking  late  in,  121 

white  patch  on  pericardium  in,  118 

white  patch  on  spleen  in,  119 
Rules  for  choosing  nurse,  41 


SALIVA,  secretion  of,  32 
Salts,  their  value  in  nutrition,  32 
Santonine,  in  treatment  of  worms,  180 

occasional  effects  of,  180 
Scaly  eruptions    in    inherited    syphilis, 

136 
Scapula,  deformities  of,  in  rickets,  103 
Schneiderian  membrane,  mucous  patches 

on,  135 
Screaming  fits  in  children,  36 
Scrofulous  diathesis,  type  of,  187 
pneumonia.     See  Pneumonia. 
Sea-air  in  rickets,  128 

in  tuberculosis,  197 
Second  dentition  a  cause  of  mucous  dis- 
ease, 161 
Secondary   acute    diseases   common    in 
wasted  children,  19 
peculiarities  of,  20 
Septum  nasi,  perforation  of,  135 
Serous  effusions  in  chronic  diarrhoea,  63 
Shampooing  in  chronic  tuberculosis,  199 

in  rickets,  130 
Shape  of  chest  in  rickets,  101 

in  the  tubercular  diathesis,  189 
Sickness  from  acidity,  treatment  of,  59 
Sign  of  hunger  in  infants,  43 
Silver,  nitrate  of,  in  chronic  diarrhoea, 

82 
Simple  atrophy,  29 
causes  of,  29 
symptoms  of,  34 
treatment  of,  40 
Size  of  liver,  to  estimate,  23 

of  spleen,  24 
Skin,  tint  of,  in  chronic  diarrhoea,  61 

in  inherited  syphilis,  137 
Skull,  shape  of,  in  rickets,  98 
Slimy  tongue,  a  sign  of  mucous  disease, 

157 
Smile  during  sleep,  of  infants,  36 


264: 


INDEX. 


Snuffling  in  syphilis,  134 

Soap  suppository  for  constipation,  53 

to  be  used  for  washing  infants,  52 
Softening  of  mesenteric  glands,  233 
of  pneumonic  deposit,  212 
of  tubercle,  212 
of  tubercular  glands,  235 
Soils,  influence  of,  in  phthisis,  196 
Somnambulism  in  miicous  disease,  157 
Sour  smell  of  breath  in  chronic  vomiting, 

87 
Spasmodic  cough  in  bronchial  phthisis, 

229 
Spine,  deformities  of,  in  rickets,  100 
Spleen,  albuminoid  degeneration  of,  120 
enlargement  of,  in  inherited  syphi- 
lis, 140 
method  of  examining,  24 
Sprays,  alkaline,  225 

astringent,  225 
Spurious  hydrocephalus,  88 
diagnosis  of,  89 
treatment  of,  94 
Sputum,  elastic  tissue  in,  219 
Stethoscope,  use  of,  in  examining  infants, 

208 
Stethoscopic  signs  in  pulmonary  phthisis, 

208 
Stimulant    expectorants     in     phthisis, 

224 
Stimulants,  28 

indications  for  giving,  22 
Stomach,  irritability  of,  57 

in  inherited  syphilis,  139,  146 
Stools,  blood  in,  cause  of,  61,  02 

character  of,  in  chronic  diarrhoea, 

61,  62 
examination  of,  in  cases  of  wasting, 

34,  61 
pus  in,  62 
Stripping  children  for  examination,  22 
Strophulus  a  sign  of  indigestion,  37 
Suckling,  first  time  of,  42 

frequency  of,  42 
Sugar  as  a  substitute  for  cod-liver  oil, 
202 
its  use  in  nutrition,  32 
of  milk  in  artificial  feeding,  44 
Superficial  veins  of  abdominal  wall  en- 
larged, 232 
of  face,  enlargement  of,  228 
Supraspinous  fossa,  duluess  at,  206 
Symptoms  of  bronchial  phthisis,  228 
of  chronic  diarrhoea,  60 
of  chronic  pulmonary  phthisis,  204 
of  chronic  tuberculosis,  188 
of  chronic  vomiting,  86 
of  inherited  syphilis,  133 
of  mucous  disease,  156 
of  rickets,  96 
of  simple  atrophy,  34 
of  worms,  174 


Syphilis  and  rickets,  connection  between, 
126 
inherited.     See  Inherited  syphilis. 
miscarriage  a  result  of,  134 
secretion  of  milk  in,  151 
Syphilitic  coryza,  135 
Syrup  of  iodide  of  iron  in  inherited  sy- 
philis, 155 
System,  the  hardening,  196 


TABES  MESENTERICA,  abdomen  in,  23, 
231 
anatomical  characters  of,  236 
ascites  in,  232 

cramps  of  extremities  in,  232 
diagnosis  of,  233 
peritonitis  as  a  result  of,  233 
pressure  on  veins  in,  232 
symptoms,  231 
tenderness  of  belly  in,  232 
treatment  of,  236 
Tjenia  medio-canellata,  171 

solium,  171 
Talking  late  in  rickets,  109 
Tannin  in  treatment  of  rickets,  130 
Tears  a  good  sign  in  chronic  diarrhoea, 

65,72 
Teeth,  care  required  during  cutting  of,  74 
early  decay  of,  in  rickets,  100 
late  appearance  of,  in  rickets,  100 
permanent  malformation  of,  141 
Teething  in  chronic  diarrhoea,  iiio 
in  inherited  syphilis,  138 
in  rickets,  100 
in  tuberculosis,  187- 
Temperature,  changes  of,  a  cause  of  di- 
arrhoea, 74 
precautions  against,  73 
in  scrofulous  pneumonia,  216 
in  tubercular  ulceration  of  bowels, 

71 
in  tuberculosis,  191 
Tenderness,  general,  in  rickets,  96 

of  belly  in  tabes  meseuterica,  232 
Test  of  a  good  nurse,  31,  41 
Thermometer  in  diagnosis  of  mucous  dis- 
ease, 161 
of  pulmonary  phthisis,  216 
of  tubercle  of  bowels,  71 
of  tuberculosis,  191 
Thighbone,  deformities  of,  in  rickets,  104 
Thorax,  shape  of,  in  rickets,  101 

tuberculosis,  189 
Thrombosis  of  cerebral  sinuses,  63 
Thrush,  37 

a  cause  of  refusal  of  breast,  51 
treatment  of,  5 
value  of,  in  prognosis,  37 
Thymus  gland,  disease  of,  in  inherited 
syphilis,  134 
in  rickets,  120 


IXDEX, 


265 


Tibia,  deformities  of,  in  rickets,  104 

Time  of  first  suckling,  42 

Tint  of  skin  in  chronic  diarrhoea,  61 

inherited  sypliilis,  137 
Tissue,  elastic,  in  sputum,  219 
Tongue  in  acute  indigestion,  39 
chronic  diarrhoea,  62 
chronic  vomiting,  87 
mucous  disease,  51 
Tongue-tie  an  obstacle  to  sucking,  51 

rarity  of,  51,  note 
Tonics,  27 

in  inherited  syphilis,  155 
rickets,  129 
Tonsils,  cheesy,  221 

treatment  of,  223 
Trachea,  pressure  on,  in  bronchial  plitlii- 

sis,  229 
"  Traits,"  M.  Jadelot's,  21 
Treatment,  general,  of  wasting,  24 

of  acidity  of  stomach  in  infants,  54 
of  aphthae,  58 
of  bronchial  phthisis,  236 
of  catarrh  in  rickets,  130 
of  chronic  diarrlioea,  75 
phthisis,  222 
tuberculosis,  197 
of  chronic  vomiting,  89 
of  cheesy  tonsils,  223 
of  colic  in  infants,  57 
constipation  in  infants,  53 
of  convulsions  from  indigestion,  58 

in  rickets,  132 
of  diarrhoea  in  inherited    syphilis, 
153 
in  rickets,  131 
of  inlierited  syphilis,  147 
of  laryngismus  stridulus,  132 
of  mucous  disease,  162 
of  prolapsus  ani,  183 
of  rickets,  127 
of  simple  atrophy,  40 
of  spurious  hydrocephalus,  94 
of  tabes  mesenterica,  236 
of  thrush,  58 

of  vomiting  in  inherited  syphilis, 
153 
from  acute  gastric  catarrh,  86 
of  worms,  179^ 
Tricocephalus  dispar,  170 
treatment  of,  180 
Tubercle  in  rickets,  112 
infiltrated  yellow,  210 
inoculability  of,  194,  note 
miliary,  185,  209 
of  lung,  210 

complicating   scrofulous  pneu- 
monia, 212 
diagnosis  of,  217 
physical  signs  of,  206 
treatment  of,  222 
Tubercles,  seat  of,  in  lung,  209 


I  Tiiberculizah'on  of  glands,  226 
I  bronchial  glands,  227 

of  mesenteric  glands,  231 
Tuberculosis,  chronic,  184 
causes  of,  193 
diagnosis  of,  191 
diet  in,  199,  251 
exercise  in,  198 
pigeon-breast  in,  189 
prevention  of,  195 
symptoms  of,  188 
temperature  in,  191 
treatment  of,  197 
Tuberculous  ulceration  of  bowels,  70 
Tumor,  seat  of,  in  tabes  mesenterica,  232 
Turpentine  in  treatment  of  convulsions, 
58 
in  treatment  of  tapeworm,  181 
Type  of  scrofulous  diathesis,  187 
tuberculous  diathesis,  187 


ULCERATION  of  bowels,  symptoms  of, 
62 

tuberculous,  70 
of  mucous  membrane  of  nose,  135 
Ulcerations,  linear,  in  inherited  syphilis, 

137 
Unsuitable  food  a  cause  of  simple  atro- 
phy, 31 
Urine,  incontinence  of,  in  mucous  dis- 
ease, 157 
Urine  in  rickets,  120 
Urticaria  a  sign  of  indigestion,  37 


VACCINATION  as  a  means  of  commu- 
nicating syphilis,  144 
Value  of  aromatics  for  infants,  55,  81 
stethoscopic  signs  in  infantile  phthi- 
sis, 208 
Value  of  thermometer  iu    diagnosis  of 

tuberculosis,  191 
Varieties  of  breast-milk,  30 
Vein,  portal,  pressure  on,  232 
Veins,  pressure  on,  in  tabes  mesenterica, 

232 
Vena  cava,  superior,  pressure  on,  228 
Venous  engorgement  of  face  and  neck, 

228 
Vernois  and  Becquerel,MM.,on  woman's 

milk,  30 
Virchow's  views  on  bone  disease  in  rick- 
ets, 115 
Vocal  vibration  in  infants,  206 
Voluntary  muscles  in  rickets,  120 
Vomiting,  chronic,  86 
alkalies  in,  92 
bowels  in,  87 
causes  of,  88 
diagnosis  of,  89 
diet  in,  39,  89 


266 


INDEX. 


Vomitiug,  chronic — 

emetics  in,  93 
mode  of  death  in,  88 
prussic  acid  for,  92 
sour  smell  of  breath  in,  87 
spurious  hydrocephalus  in,  88 
stimulants  in,  94 
tongue  in,  88 

warmth,  importance  of,  in,  91 
danger  of,  in  inherited  syphilis,  138, 

146 
in  acute  indigestion,  39 
in  inherited  syphilis,  treatment  of, 
153 


"IITALKINCt,  lateness  of,  in  rickets,  121 
T  T       Warm  bath  for  constipation,  54 
Warmth  in  chronic  dianhoea,  75 
vomitiug,  91 

in  inherited  syphilis,  152 
Wasting,  causes  of,  17 

from  overfeeding,  32 

in  inherited  syphilis,  138 

in  rickets,  113 

not  always  present,  120 
Weak  respiration,  209 
Weanini:,  dentition  no  guide  to,  49 

method  of,  50 


Weaning — 

premature,  sometimes  necessary,  50 

time  of,  49 
Wet  nurse,  rules  for  choosing,  41 

test  of  a  good,  31 
White  patch  on  pericardium  in  rickets, 
118 
on  spleen  in  rickets,  119 
Whitlow  in  inherited  syphilis,  137 
Whooping-cough  a  cause  of  mucous  dis- 
ease, 160 
Woman's  milk,  30 
Worms,  169 

appearance  of  tongue  in,  195 

ascaris  lumbricoides,  170 

bothriocephalus  latus,  171 

convulsions   from,  175 

diagnosis  of,  177 

migrations  of,  175 

oxyuris  vermicularis,  169 

symptoms,  174 

taenia  medio-canellata,  171 
solium,  171 

treatment  of,  179 

tricocephalus  dispar,  170 


yELLOW  granulations,  185 


A  New  American  Work  on  Children-Just  Issued. 
A  TRE4TISE  ON^E  DISEASES  OF 

INFANCY  AND  CHILDHOOD. 

By  J.  LEWIS  SMITH,  M.D., 

Curator  to  tho  Nursery  and  Child's  Hospital,  New  York  ;  Physician  to  the  Infants'  Hospital, 
Ward's  Island  ;  Professor  in  Bellevue  Hospital  Medical  College,  New  York. 

In  one  large  and  handsome  octavo  volume  o/"620  pages  :  extra  doth,  $4  75  ;  leather,  $5  75. 

It  is  in  many  respects  one  of  the  best  works  on 
infantile  disease  we  have  met  with.  The  latest 
views  are  clearly  discussed  iu  it,  and  it  has  a 
special  advantage  in  being  one  of  the  most  reli- 
able guides  as  regards  practice  with  which  we 


are  acquainted.  Indeed,  we  do  not  hesitate  to 
place  it  first  on  the  list  in  this  respect.  In  our 
opinion,  iu  uo  class  of  cases  is  the  so-called  "re- 
storative treatment  of  disease"  so  essential  as  in 
the  young,  and  we  know  of  no  systematic  woi-k 
in  which  this  fact  is  so  thoroughly  recognized  as 
in  Dr.  Smith'.s. — Brit,  and  For.  Med.-Chirurg. 
Revieio,  Oct.  1S70. 

The  excellence  of  this  book  is  one  explanation 
of  our  not  having  reviewed  it  sooner.  Taking  it 
up  from  time  to  time,  we  have  been  freshly  inte- 
rested in  its  various  chapters,  and  so  been  led  to 
defer  writing  our  opiuion  of  it.  It  is  one  of  those 
works  with  which  we  are  happily  becoming  fami- 
liar, as  coming  to  us  from  time  to  time  from  across 
the  Atlantic,  which  contain  all  that  is  good  in 
European  works  of  the  same  kind,  together  with 
much  that  is  original,  both  in  reflection  and  ob- 
servation. It  is  astonishing  how  well  the  Ameri- 
can writers  succeed  in  gleaning,  and  yet  giving  a 
fresh  character  to  their  books.  This  work  is  an 
illustration,  and  pervading  every  chapter  of  it  is 
a  spirit  of  sound  judgment  and  common  sense, 
without  which  any  work  on  any  department  of 
the  practice  of  medicine  is,  to  use  the  mildest 
word,  defective.  We  are  sorry  that  we  cannot 
give  further  ilhi.>'tralions  of  the  excellence  of  this 
book. — London  Lancet,  Sept.  4,  1S69. 

After  an  examination  of  this  book,  we  think  we 
are  not  mistaken  iu  welcoming  its  writer  as  a  new 


better  form  a  notion  of  the  industry  and  good 
judgment  of  its  author  by  au  extended  perusal 
of  it,  that  we  have  concluded  to  simply  refer  them 
to  the  book  itself — St.  Louis  Med.  and  Surg. 
Jotirnal,  May  10,  1S69. 


Most  heartily  do  we  wish  the  work  the  success 
it  so  richly  deserves. — Am.  Journ.  o/Obstet.,  *c., 
May,  1869. 

The  work  before  us  is  a  valuable  addition  to 
the  text-books  of  the  subject.  While  it  covers 
the  gronnd  of  the  recognized  principles  and  treat- 
ment of  the  diseases  of  childhood  and  infancy,  it 
teems  with  a  freshness  of  suggestion  and  resource 
which  will  insure  it  a  place  in  every  physician's 
lihrnvy. —LeavemoortJi  Med.  Herald,  May,  1S69. 

The  remarkable  faculty  of  bringing  out  salient 
points  and  stating  concisely  other  less  impiu'tant 
facts,  enables  him  to  crowd  within  a  small  com- 
pass a  vast  amount  of  practical  information.  The 
attention  given  to  the  treatment  of  the  various 
maladies,  as  well  as  the  presentation  of  all  the 
recently  accepted  pathological  views,  make  it  one 
of  the  most  valuable  treatises,  within  its  present 
compass,  that  can  bo  placed  in  the  hands  of  any 
seeker  after  truth.  The  volume  as  a  whole  will 
still  further  establish  for  the  writer  a  permanent 
and  enviable  reputation  as  a  careful  observer,  an 
impartial  interpreter,  a  safe  and  trustworthy  ad- 
viser, and  a  modest  and  untiring  student. — N.  Y. 
Med.  Record,  March  1.9,  1869. 

We  have  perused  Dr.  Smith's  book  with  not  a 
little  satisfaction;  it  is  indeed  an  excellent  work  ; 
well  and  correctly  written  ;  thoroughly  up  to  the 


authority  in  medical  literature  on  the  diseases  of  modern  ideas;  concise,  yet  complete  iu  its  mate- 
children.  The  sources  of  his  information  are  rial.  We  cannot  help  welcoming  a  work  which 
copious,  and  he  seems  to  have  made  careful  use  I  will  be  worthy  of  reliance  as  a  text-book  for  med- 
of  them.  We  had  intended  to  support  these  opi-  ical  students  and  younger  physicians  in  their  iu- 
nions  by  qnotations,  but  the  range  of  the  work  is  j  vestigations  of  disease  in  children. — Boston  Med. 
so  comprehen.sive,  and  our  readers  can  so  much  I  and  Surg.  Journal,  March  4,  1S69. 


New  and  Enlarged  Edition— Just  Issued. 

LECTURES~ON  THE 

DISEASES  OF  IISTFAN^OY  XED  CHILDHOOD. 

By  CHARLES  WEST,  M.  D., 

Physician  to  the  Hospital  for  Sick  Children,  &c. 

Fourth  American,  from  the  Fifth  Enlarged  and  Improved  London  Edition. 

In  one  neat  octavo  volume  o/656  large  pages :  extra  cloth,  $4  50;  leather,  $5  50. 

Of  all  the  English  writers  on  the  diseases  of 
children,  there  is  no  one  so  entirely  satisfactory 
to  us  as  Dr.  West.  For  years  we  have  held  his 
opinion  as  judicial,  and  have  regarded  him  as 
one  of  the  highest  living  authorities  in  the  difli- 
cult  department  of  medical  science  in  which  he 
is  most  widely  known.  His  writings  are  charac- 
terized by  a  sound,  practical  common  sense,  at 
the  same  time  that  they  bear  the  marks  of  the 
most  laborious  study  and  investigation.  We  com- 
mend it  to  all  as  a  most  reliable  adviser  on  many 
occasions  when  many  treatises  on  the  same  sub- 
ject will  utterly  fail  to  help  us.  It  is  supplie<l 
with  a  very  copious  general  index,  and  a  special 
index  to  the  formula?  scattered  throughout  the 
■work. — Boston  Med.  and  Surg.  Journal,  April 
26,  1866.  


Dr.  Wesfs  volume  is,  in  our  opinion,  incom- 
parably the  best  authority  upon  the  maladies  of 
children  that  the  practitioner  can  consult.  With- 
al, loo — a  minor  matter  truly,  but  still  not  one 
that  should  be  neglected — Dr.  West's  composition 
possesses  a  peculiar  charm,  beauty,  and  clearness 
of  expression,  thus  atfording  the  reader  much 
pleasure,  even  independent  of  that  which  arises 
from  the  acquisition  of  valuable  truths. — Cincin- 
nati Journal  of  Medicine,  March,  1865. 

We  have  long  regarded  it  as  the  most  scientific 
and  practical  book  on  diseases  of  children  which 
has  yet  appeared  in  this  country. — Buffalo  Med. 
Journal. 


HENRY    C.    LEA-PViiladelphia. 


New  and  Improved  Edition — Just  Issued. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

By  D.  FRA.NCIS  CONDIE,  M.D. 

SIXTH  EDITION,  REVISED  AND  ENLARGED. 

In  one  large  octavo  vol.  of  nearly  eight  hundred  pages  :  extra  cloth,  $3  25  ;  leather,  f6  25. 

No  other  treatise  on  this  subject  is  better 
adapted  to  the  American  physician.  Dr.  Condie 
has  long  stood  before  his  countrymen  as  one 
peculiarly  pre-eminent  in  this  department  of 
medicine.  His  work  has  been  go  long  a  standard 
for  practitioners  and  medical  etiideuts  that  we 
do  no  more  now  than  refer  to  the  fact  that  it  lias 


Dr.  Condie  has  been  one  of  those  who  have 
performed  such  a  service  satisfactorily,  and,  as  a 
result,  bis  jiopular,  comprehensive,  and  practical 
work  has  received  that  high  compliment  of  ap- 
proval on  the  part  of  his  brethren,  which  several 
editions  incontestahly  set  forth.  The  present  edi- 
tion, which  is  the  sixth,  is  fully  up  to  the  times 
in  the  discussion  of  all  those  points  in  the  patho-  i  reached  its  sixth  edition.  We  are  glad  once  more 
logy  and  treatment  of  infantile  diseases  which  |  to  refresh  the  impressions  of  our  earlier  days  by 
liave  been  brought  forward  by  the  German  and  I  wandering  through  its  pages,  and  at  the  same 
French  teachers.  As  a  whole,  however,  the  work  I  time  to  be  able  to  recommend  it  to  the  youngest 
is  the  best  American  one  that  we  have,  and  in  its  members  of  the  profession,  as  well  as  to  those 
special  adaptation  to  American  practitioners  it  who  have  the  older  editions  on  their  shelves  — 
certainly  has  no  equal. — New  York  Med.  Record,  St.  Louis  Med.  Reporter,  Feb.  15,  1S6S. 
March  2,  1S6S.  ' 


PUBLISHING  IN  THE  MEDICAL  NEWS  AND  LIBRARY  FOR  1S71-72. 

SURGICAL  DISEASES  OF  INFANTS  AND  CHILDREN. 

By  M.  P.  GUERSANT, 

Honorary  Surgeon  to  the  Hospital  for  Sick  Children,  Paris. 

Translated  BY  RICHARD   J.    DUNGLISON,    M.D. 

Twenty  years'  service  as  surgeon  in  the  great  Children's  Hospital  of  Paris  has  given  to 
M.  Guersant  the  right  to  speak  as  an  authority  on  all  subjects  connected  with  the  branch 
of  practice  to  which  he  has  devoted  himself.  In  this  work  he  has  endeavored  to  record 
the  results  of  his  experience  plainly  and  truthfully,  and  to  render  it  a  practical  guide  for 
the  physician  who  is  called  upon  to  treat  the  accidents  and  diseases  to  which  childhood  is 
liable.  The  following  synopsis  of  the  contents  will  show  how  large  an  amount  of  practical 
matter  he  has  succeeded  in  condensing  within  a  moderate  compass,  embracing  much  which, 
while  of  every- day  importance,  can  scarcely  be  found  in  the  ordinary  text-books. 

SUMMARY    OF    CONTENTS. 

I.  Surgical  Operations  on  Children.  II.  Cervical  Adenitis.  III.  Phimosis.  IV.  Fractures.  V. 
Tracheotomy  in  Croup.  VI.  Hypertrophy  of  the  Tonsils.  VII.  Polypus  of  the  Rectum.  VIII. 
Najvi  Mateini.  IX.  Cysts  and  Encysted  Tumors.  X  Lithotomy  and  Lithotrity.  XI.  Hydrocele. 
XII.  Prolapsus  of  Rectum.  XIII.  Chronic  Arthritis.  XIV.  Burns.  XV.  Hare-lip.  XVI.  Coxalgia. 
XVII.  Irrigation  of  the  I'harynx.  XVIII.  Vulvitis.  XIX.  Foreign  Bodies  in  the  Ear.  XX.  Cataract. 
XXI.  Abdominal  Hernia.  XXII.  Leucorrhoea.  XXIII.  Wry-neck  XXIV.  Malformations  of  Fingers 
and  Toes.  XXV.  Pott's  Disease  of  the  Spine.  XXVI.  Congenital  Imperforation  of  Anus.  XXVII. 
Traumatic  Luxation  of  Femur  XXVIII.  Foreign  Bodies  in  Air- Passages.  XXIX.  Purulent  Oph- 
thalmia of  the  New  born.  XXX.  Incontinence  of  Urine.  XXXI.  Cancer  of  the  Eye.  XXXII. 
Club-Foot.  XXXIII.  Cancer  of  Testis.  XXXIV.  Encephalocele.  XXXV.  Caphalotoma.  XXXVI. 
Hypospadias  and  Epispadias.  XXXVII.  Ranula.  XXXVIII.  Inflammation  of  the  Breast.  XXXIX. 
Osteitis.  XL.  Caries.  XLI.  Necrosis.  XLII.  Oculo-palpebral  Conjunctivitis  XLIII.  Injuries 
of  the  Cornea.  XLIV.  Chilblains.  XLV.  Traumatic  Dislocations.  XLVI.  Erysipelas.  XLVII. 
Sprains.  XLVIII.  Ozena.  XLIX.  Lachrymal  Fistula.  L.  Anaesthesia.  LI.  Phlegmon  Lll. 
Ceratitis.  LIII.  Strabismus.  LIV.  Cynanche  parotidea.  LV.  Spina  bifida.  LVI  Tougue-Tie. 
LVII.  Prolapsus  of  Urethra.  LVIII.  Pemphigus.  LIX.  Thoracentesis.  LX.  Ectropion  LXI. 
Eulropion.  LXII.  Trichiasis.  LXIII.  Naso-Pharyugeal  Polypus.  LXIV.  Onychia.  LXV.  Ab- 
normal Cicatrices.  LXVI  Diseases  of  the  Umbilicus.  LXVII.  Epiphyseal  Separations.  LXVIII. 
Cutaneous  Tumors.  LXIX.  Injuries  of  the  Fingers.  LXX  Lancing  of  the  Gum.  LXXI  Abscess 
of  Nasal  Septum.     LXXII.  Congenital  Luxations.     LXXIII.  Foreign  Bodies  in  the  (Esophagus. 

It  is  therefore  hoped  that  this  volume  will  be  found  to  fully  sustain  the  reputation  of  the 
valuable  series  of  practical  works  which  have  been  published  in  the  Library  Department 
of  the  "Medical  News,"  and  have  thus  been  received  without  cost  by  the  subscribers 
of  the  "  American  Journal  of  the  Medical  Sciences." 


DEWEES  ON  THE  PHYSICAL  AND  MEDICAL  TREATMENT 

OF  CHILDREN.    Eleventh  edition,  with  the  author's  last  improvements  and  correc- 
tions.    In  one  octavo  volume  of  548  pages.     $2  SO. 

HENRY    C.   LEA,   Philadelphia. 


HEHSTRY     C.    L  E  ^' S 

(LATE  LEA  k  BLANCHABD'S) 
OF 

MEDICAL  AND  SUEGICAL  PUBLICATIONS. 


In  asking  the  attention  of  the  profession  to  the  works  contained  in  the  following 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Illustrated  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  postpaid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA. 

Nm.  706  and  708  Sansom  St.,  Philadelphia,  Nov.  1870. 


ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


THEEE  MEDICAL  JOUENALS,  containing  over  2000  LAEGE  PAGES, 

Tree  of  Postage,  for  SIX  DOLLAES  Per  Annum. 


TERMS   FOR  1871: 

The  American  Journal  of  the  Medical  Sciences,  and  1  Five  Dollars  per  annum, 
The  Medical  News  and  Library,  both  free  of  postage,      )  in  advance. 

OR., 

The  American  Journal  of  the  Medihal  Sciences,  published  quar-")  gj^  Dollars 

terly  (1150  pages  per  annum),  with 
The  Medical  News  and  Library,  raoulbly  (384  pp.  per  annum),  and  \  per  annum 
The  Half-Yearly  Abstract  of  the  Medical  Sciences,  published     ^^  advance 

Feb.  and  August  (600  pages  per  annum),  all  free  of  postage.     J 

SEPAItATE  SUBSCBIPTIOyS  TO 

The  American  Journal  of  the  Medical  Sciences,  subject  to  postage  when  not  paid 
for  in  advance.  Five  Dollars. 

The  Medical  News  and  Library,  free  of  postage,  in  advance.  One  Dollar. 

The  Half-Yearly  Abstract,  Two  Dollars  and  a  Half  per  annum  in  advance.    Single 
numbers  One  Dollar  and  a  Half. 

It  is  manifest  that  only  a  very  wide  circulation  can  enable  so  vast  an  amount  of 
valuable  practical  matter  to  be  supplied  at  a  price  so  unprecedentedly  low.     'J'he  pub- 
lisher, therefore,  has  much  gratification  in  stating  that  the  rapid  and  steady  increase 
in  the  subscripliou  list  promises  to  render  the  enterprise  a  pei  munent  one,  and  it  is 
1 


2         Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 

with  especial  pleasure  that  he  acknowledges  the  valuable  assistance  spontaneously 
rendered  by  so  many  of  the  old  subscribers  to  the  "  Journal,"  who  have  kindly  made 
known  among  their  friends  the  advantages  thus  offered  and  have  induced  them  to 
subscribe.  Eelying  upon  a  continuance  of  these  friendly  exertions,  he  hopes  to  be 
able  to  maintain  the  unexampled  rates  at  which  these  works  are  now  supplied,  and  to 
succeed  in  his  endeavor  to  place  upon  the  table  of  every  reading  practitioner  in  the 
United  States  a  monthly,  a  quarterly,  and  a  half-yearly  periodical  at  the  comparatively 
trifling  cost  of  Six  Dollars  pei-  annum. 

These  periodicals  are  universally  known  for  their  high  professional  standing  in  their 
several  spheres. 

I. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  ISAAC  HAYS,  M.D., 

is  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each 
number  contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated, 
wherever  necessary.  It  has  now  been  issued  regularly  for  over  forty  years,  during 
nearly  the  whole  of  which  time  it  has  been  under  the  control  of  the  present  editor. 
Throughout  this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of 
medical  periodicals  both  at  home  and  abroad,  and  has  received  the  cordial  support  of 
the  entire  profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large 
number  of  the  most  distinguished  names  of  the  profession  in  every  section  of  the 
United  States,  rendering  the  department  devoted  to 

ORIGINAL    COMMUNICATIONS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
1H70,  articles  have  appeared  in  its  pages  from  one  hundred  and  eight  gentlemen  of 
the  highest  standing  in  the  profession  throughout  the  United  States.* 

Following  this  is  the  "Review  Department,"  containing  extended  and  impartial 
'reviews  of  all  important  new  works,  together  with  numerous  elaborate  "Analytical 
and  Bibliographical  Notices"  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  "  Quarterly  Summary  of  Improvements  and  Discoveries 
IN  THE  Medical  Sciences,"  classified  and  arranged  under  diiferent  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  1870,  the  "Journal"  furnished  to  its  subscribers  One 
Hundred  and  Sixty-two  Original  Communications,  Eighty-two  Reviews  and  Biblio- 
graphical Notices,  and  Three  Hundred  and  four  articles  in  the  Quarterly  Summaries, 
making  a  total  of  about  Five  Hundred  and  Fifty  articles  emanating  from  the  best 
profes?ional  minds  in  America  and  Europe. 

To  old  subscribers,  many  of  whom  have  been  on  the  list  for  twenty  or  thirty  years, 
the  publisher  feels  that  no  promises  for  the  future  are  necessary;  but  gentlemen  who 
may  now  propose  for  the  first  time  to  subscribe  may  rest  assured  that  no  exertion  will 
be  spared  to  maintain  the  "Journal"  in  the  high  position  which  it  has  so  long  occu- 
pied ("one  of  the  best  of  its  kind," — London  Lancet,  Aug.  20,  1870),  as  a  national 
exponent  of  scientific  medicine,  and  as  a  medium  of  intercommunication  between  the 
profession  of  Europe  and  America — in  the  words  of  the  "London  Medical  Times" 
(Sept.  5th,  1868)  "almost  the  only  one  that  circulates  everywhere,  all  over  the  Union 
and  in  Europe" — to  render  it,  in  fact,  necessary  to  every  practitioner  who  desires  to 
keep  on  a  level  with  the  progress  of  his  science. 

The  subscription  price  of  the  "American  Journal  op  the  Medical  Sciences"  has 
never  been  raised,  during  its  long  career.  It  is  still  Five  Dollars  per  annum ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical  News  and 
Library,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  LIBRARY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "News  Department"  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings;  while  the  "  Library  Department"  is  de- 
voted to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 

*  CommunicationB  lire  Invited  from  gentlemen  In  all  parts  of  the  country.  Elaborate  articles  inserted 
bv  'he  Editor  are  paid  for  by  tne  Pablisher. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 


separately,  so  that  they  can  be  removed  and  bound  on  compleHon.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  ••  Watson's  Practice." 
"Todd  and  Bow.mans  Physiology,"  "  Wkst  on  Childrkn,"  "  Mai.gaionk's  Slrgerv," 
&c.  &c.  And  with  Januury,  1871,  will  be  commenced  a  new  and  vahuiblo  work,  ren- 
dering this  a  ver\  eligible  period  for  the  commencement  of  new  subscriptions. 

As  stated  above,  the  subscription  price  of  the  ".Mrdicai,  News  and  Library"  is 
One  Dollar  per  annum  in  advance ;  and  it  is  furnished  without  charge  to  all  advance 
paying  subscribers  to  the  ''AMEiuoAN  Journal  of  the  Medical  Sciences." 

III. 

THE  HALF-YEARLY  ABSTRACT  OF  THE  MEDICAL  SCIENCES 

is  issued  in  half-yearly  volumes,  which  will  be  delivered  to  subscpibers  about  the  first 
of  February,  and  first  of  August.  Each  volume  contains  about  300  closely  printed 
octavo  pages,  making  about  six  hundred  pages  per  annum. 

" Banking's  Abstract"  has  now  been  published  in  England  regularly  for  more  than 
twenty  years,  and  has  acquired  the  highest  reputation  for  the  ability  and  industry 
with  which  the  essence  of  medical  literature  is  condensed  into  its  pages.  It  pur- 
ports to  be  "A  Digest  of  British  and  Continental  Medicine,  and  of  the  Progress  of 
Medicine  and  the  Collateral  Scie7ices,"  and  it  is  even  more  than  this,  for  America  is 
largely  represented  in  its  pages.  It  draws  its  material  not  only  from  all  the  leading 
American,  British,  and  Continental  journals,  but  also  from  the  medical  works  and 
treatises  issued  during  the  preceding  six  months,  thus  giving  a  complete  digest  of 
medical  progress.  Each  article  is  carefully  condensed,  so  as  to  present  its  substance 
in  the  smallest  possible  compass,  thus  affording  space  for  the  very  large  amount  of  infor- 
mation laid  before  its  readers.     The  volumes  of  1870,  for  instance,  have  contained 

FORTY-THREE  ARTICLES  ON  GENERAL  QUESTIONS  IN  MEDICINE. 

NINETY-FIVE  ARTICLES  ON  SPECIAL  QUESTIONS  IN  MEDICINE. 

TWENTY-THREE  ARTICLES  ON  FORENSIC  MEDICINE. 

KINETY-NINE  ARTICLES  ON  THERAPEUTICS. 

FOUTY-FOCR  ARTICLES  ON  GENERAL  QUESTIONS  IN  SURGERY. 

ONE  HUNDRED  AND  FIFTY-SIX  ARTICLES  ON  SPECIAL  QUESTIONS  IN  SURGERY. 

NINETY-EIGHT  ARTICLES  ON  MIDWIFERY  AND  DISEASES  OF  WOMEN  AND  CHILDREN. 

TWO  ARTICLES  IN  APPENDIX. 

Making  in  all  over  five  hundred  and  fifty  articles  in  a  single  year.  Each  volume, 
moreover,  is  systematically  arranged,  with  an  elaborate  Table  of  Contents  and  a  very 
full  Index,  thus  facilitating  the  researches  of  the  reader  in  pursuit  of  particular  sub- 
jects, and  enabling  him  to  refer  without  loss  of  time  to  the  vast  amount  of  information 
contained  in  its  pages. 

The  subscription  price  of  the  "Abstract,"  mailed  free  of  postage,  is  Two 
Dollars  and  a  Half  per  annum,  payable  in  advance.     Single  volumes,  $1  50  each. 

As  stated  above,  however,  it  will,  be  supplied  in  conjunction  with  the  "A.mkri(;an 
Journal  of  the  Medical  Sciences"  and  the  "Medical  News  and  Library,"  the 
"whole  free  of  postage,  for  Six  Dollars  per  annum  in  advance. 

For  this  small  sinn  the  subscriber  will  therefore  receive  three  periodicals  costing 
separately  Eight  Dollars  and  a  Half,  each  of  them  enjoying  the  highest  reputation  in 
its  class,  containing  in  all  over  two  thousand  pages  of  the  choicest  reading,  and  pre- 
senting a  complete  view  of  medical  progress  throughout  both  hemispheres. 

In  this  effort  to  bring  so  large  an  amouut  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature  on 
a  footing  of  cheapness  never  heretofore  attempted. 

*»*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1871,  as  the  constant  increase  in  the  subscription  list  almost 
always  exhausts  the  quantity  printed  shortly  after  publication. 

^"  The  safest  mode  of  remittance  is  by  postal  money  order,  drawn  to  the  order  of 
the  undersigned.  ^Yhere  money  order  post-offices  are  not  accessible,  remittances  tor 
the  "Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.     Address, 

HENRY  C.  LEA, 

Nos.  706  and  708  Sansom  St..  Philadklphta,  Pa. 


Henry  C.  Lea's  Publications — {Dictionaries). 


TiUNGLISON  [ROBLEY),  M.D., 

'^'^  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  PhikuUlphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:   Con- 
taining a  concise  "xplanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene.  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Ofi6cinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.    Thoroughly  Revised,  and  very  greatly  Modified  and  Augmented. 
In  one  very  large  and  handsome  royal  octavo  volume  of  1048  double-columned  pagea,  in 
small  type;  strongly  done  up  in  extra  cloth,  $6  00;  leather,  raised  bands,  $6  75. 
The  object  of  the  author  from  the  outset  has  not  been,  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afTord,  under  each,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken.     The  mechanical  exe- 
cution of  this  edition  will  be  found  greatly  superior  to  that  of  previous  impressions.    By  enlarging 
the  size  of  the  volume  to  a  royal  octavo,  and  by  the  employment  of  a  small  but  clear  type,  on 
extra  fine  paper,  the  additions  have  been  incorporated  without  materially  increasing  the  bulk  of 
the  volume,  and  the  matter  of  two  or  three  ordinary  octavos  has  been  compressed  into  the  space 
of  one  not  unhandy  for  consultation  and  reference. 

It  would  be  a  work  of  supererogation  to  bestow  a 
word  of  praise  upon  this  Lexicon.  We  can  only 
wonder  at  the  labor  expended,  for  whenever  we  refer 


to  its  pageB  for  information  we  are  seldom  disap- 
pointed in  finding  all  we  desire,  whether  it  be  in  ac- 
centuation, etymology,  or  definition  of  terms. — ifew 
York  Medical  Journal,  November,  1865. 

It  would  be  mere  waste  of  words  in  us  to  express 
our  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  English  language.  As  a  book 
of  reference  it  is  invaluable  to  the  medical  practi- 
tioner, and  in  every  instance  that  we  have  turned 
over  its  pages  for  information  we  have  been  charmed 
by  the  clearness  of  language  and  the  accuracy  of 
detail  with  which  each  abounds.  We  can  most  cor- 
dially and  confidently  commend  it  to  our  readers. — 
Glasgow  Medical  Journal,  January,  1866. 

A  work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

It  is  something  more  than  a  dictionary,  and  some- 
thing less  than  an  encyclopedia.  This  edition  of  the 
well-known  work  is  a  great  improvement  on  its  pre- 
decessors. The  book  is  one  of  the  very  few  of  which 
it  may  be  said  with  truth  that  every  medical  man 
should  possess  it— London  Medical  Times,  Aug.  26, 
1865. 

Few  works  of  the  class  exhibit  a  grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sufficient  to  testify  to  its 


It  is  undoubtedly  the  most  complete  and  useful 
medical  dictionary  hitherto  published  in  this  country, 
— Chicago  Med.  Examiner,  February,  1S65. 

What  we  take  to  be  decidedly  the  best  medical  dic- 
tionary in  the  Bnglish  language.  The  present  edition 
is  brought  fully  up  to  the  advanced  state  of  science. 
For  many  a  long  year  "Dunglison"  has  been  at  our 
elbow,  a  constant  companion  and  friend,  and  we 
greet  him  in  his  replenished  and  improved  form  with 
especial  satisfaction. — Pacific  Med.  and  Surg.  Jour- 
nal, June  27,  1865. 

This  is,  perhaps,  the  book  of  all  others  which  the 
physician  or  surgeon  should  have  on  his  shelves.  It 
is  more  needed  at  the  present  day  than  a  few  years 
back. — Canada  Med.  Journal,  July,  1865. 

It  deservedly  stands  at  the  bead,  and  cannot  be 
surpassed  in  excellence. — Buffalo  Med.  and  Surg. 
Journal,  April,  1865. 

We  can  sincerely  commend  Dr.  Dunglison's  work 
as  most  thorough,  scientific,  and  accurate.  We  have 
tested  it  by  searching  its  pages  for  new  terms,  which 
have  abounded  so  much  of  late  in  medical  nomen- 
clature, and  our  search  has  been  successful  in  every 
instance.  We  have  been  particularly  struck  with  the 
fulness  of  the  synonymy  and  the  accuracy  of  the  de- 
rivation of  words.  It  is  as  necessary  a  work  to  every 
enlightened  physician  as  Worcester's  English  Dic- 
tionary is  to  every  one  who  would  keep  up  his  know- 
ledge of  the  English  tongue  to  the  standard  of  the 
present  day.  It  is,  to  our  mind,  the  most  complete 
work  of  the  kind  with  which  we  are  acquainted.-^ 


usefulness,  and  to  the  great  service  conferred  by  Dr      __^ 

Robley  Dunglison  on  the  profession,  and  indeed  on  I  B^on  Med.  and' Surg.  Journal,  June  22,''l865. 
others,  by  its  issue.-iowriow  Lancet,  May  13,  1865  ^^  ^^^  ^^^^  ^^  ^^^^^^^  ^^^^  ^^  ^^^^  ^^  ^^  ^^^.^^j 

The  old  edition,  which  is  now  superseded  by  the    dictionary  more  complete;  no  one  better,  if  so  weU 
new,  has  been  universally  looked  upon  by  the  medi-    adapted  for  the  use  of  the  student;  no  one  that  may 
cal  prolessiou  as  a  ;work  of  immeni^e  research  and  Kg  consulted  with  more  satisfaction  by  the  medical 
great  value.     The  new  has  increased  usefulness  ;  for    piactitioner.— Jm.  Jour.  Med.  Sciences,  April,  1865. 
medicine,  in  all  its  branches,  ha»  been  making  such        ™.         ,         ,  .v  .     j-.-       i,       v,  .i 

^rogre  "  hat  many  new  terras  and  subjects  have  re-  The  value  o  the  present  edition  has  been  greatly 
c.Dtlvbeen  introdaced:  all  of  which  maybe  found  enhanced  by  the  inlrodnction  of  new  subjects  and 
LeuLij  ucru  luv   _ .j:.:,_      ,iT.ir ^  _  „  !  tcrms,  and  a  more  complcte  ctymology  aud  acccDtua- 


fui  y'defined  in  the  present  edition.  We  know  of  no 
other  dictionary  in  the  Euglish  language  that  can 
bear  a  comparison  with  it  in  point  of  completeness  of 
eubjectb  and  accuracy  of  statement.— if.  Y.  Drug- 
gists' Circular,  1865. 
For  many  years  Dunglison's  Dictionary  has  been 


tion,  which  renders  the  work  not  ouly  satisfactory 
and  desirable,  but  indispensable  to  the  physician.— 
Chicago  Med.  .Journal,  April,  1S65. 

No  intelligent  member  of  the  profession  can  or  will 
be  without  it. — St.  Louis  Med.  and  Surg.  Journal, 


the  standard  book  of  reference  with  most  practition-  April,  ISbo. 
ers  in  this  country,  and  we  can  certainly  commend  '  It  has  the  rare  merit  that  it  certainly  has  no  rival 
this  work  to  the  renewed  confidence  and  regard  of  in  the  English  language  for  accuracy  and  extent  of 
our  readers. — Oinciniudi  Lancet,  April,  1865.  :  references. — London  Medical  Gazette. 


TTOBLYN  [RICHARD  D.),  M.D. 


A  DICTIONAKY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  A  new  American  edition,  revised,  with  numerous 
addittons,  by  Isaac  Hays,  M.D.,  Editor  of  the  "American  Journal  of  the  Medical 
Sciences."  In  one  large  royal  12mo.  valurae  of  over  600  double-columned  pages;  extra 
cloth,  *1  aO  ;  leather,  $2  00. 
It  is  the  best  book  of  (]eflnition^  we  have,  and  ought  always  to  be  upon  the  student's  table.— 5o'«/ft«r'n 
Jlfei.  and  Surg.  Journal. 


Henry  C.  Lea's  Publications — (Manuals).  5 

2^EILL  [JOHN),  M.D.,    and    ^MITff  {FRANCIS  G.),  M.D., 

Prof,  of  the.  IngtUtUes  of  Medicine  in  tlie  Univ.  of  Penna. 

AX   ANALYTICAL    COMPENDIUM   OF   THE   VARIOUS 

BRANCHES  OP  MEDICAL  SCIENCE;  for  the  Use  and  Examiniition  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12iuo. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  extra  cloth,  $4;  strongly  bound 
in  leather,  with  raised  bands,  $4  75. 


The  Compend  of  Drs.  NeiU  and  Smith  is  incompara- 
bly the  most  valuable  work  of  its  class  ever  published 
In  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Maieria  Medica, 
and  Chemistry  into  a  single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of"  Neill  and  Smith's"  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class. — N.  0.  Med.  and  Surg. 
Jmtrnal. 

There  are  but  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this 
tinassnming  though  highly  instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
as  the  gold-bearing  sands  of  El  Dorado,  and  the  pre- 


cious facts  treasured  up  In  this  little  volume.  A  cnn- 
plete  portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. —  Wtst- 
ern  Lancet. 

In  the  rapid  coarse  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa- 
mination, a  compend  is  not  only  valuable,  but  it  is 
almost  a  sine  qua  nun.  The  one  before  us  is,  iu  most 
of  the  divisions,  the  most  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  Of  course  it  is  useless 
for  us  to  recommend  it  to  all  last  course  students,  but 
there  is  a  class  to  whom  we  very  sincerely  commend 
this  cheap  book  as  worth  its  weight  in  silver — that 
class  is  the  graduates  in  medicine  of  more  than  ten 
years'  standing,  who  have  not  studied  medicine 
since.  They  will  perhaps  find  out  from  it  that  the 
science  is  not  exactly  now  what  it  was  wbea  they 
left  it  off.  — r/te  Stethoncope. 


TJARTSHORNE  [HENRY),  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL   SCIENCES;   containing 

Handbooks  on   Anatomy,    Physiology,  Chemistry,  Materia   Medica,    Practical   Medicine, 
Surgery,  and  Obstetrics.     In  one  large  royal  12rao.  volume  of  1000  closely  printed  pages, 
with  over  300  illustrations  on  wood,  extra  cloth,  $4  50 ;    leather,  raised  bands,  $5  25. 
[Now  Ready.) 
The  ability  of  the  author,  and  his  practical  skill  in  condensation,  give  assurance  that  this 
work  will  prove  valuable  not  only  to  the  student  preparing  for  examination,  but  also  to  the  prac- 
titioner desirous  of  obtaining  within  a  moderate  compass,  a  view  of  the  existing  condition  of  the 
various  departments  of  science  connected  with  medicine. 

less  valuable  to  the  beginner.  Every  medical  student 
who  desires  a  reliable  refresher  to  his  memory  wh-- 
the  pressure  of  lectures  and  other  college  work  crowU 
to  prevent  him  from  having  an  opportunity  to  drink 
deeper  in  the  larger  works,  will  find  this  one  of  the 
greatest  utility.  It  is  thoroughly  trustworthy  from 
beginning  to  end;  and  as  we  have  before  intimated, 
a  remarkably  truthful  outline  sketch  of  the  present 
state  of  medical  science.  We  could  hardly  expect  it 
should  be  otherwise,  however,  under  the  charge  of 
such  a  thorough  medical  scholar  as  the  author  lia« 
already  proved  himself  to  be. — iV.  York  Mtd.  Record, 
March  15,  1869. 


This  work  is  a  remarkably  complete  one  in  its  way, 
and  comes  nearer  to  our  idea  of  what  a  Conspectus 
sljould  be  than  any  we  have  yet  seen.  Prof.  Harts- 
home,  with  a  commendable  forethought,  intrusted 
the  preparation  of  many  of  the  chapters  on  special 
subjects  to  experts,  reserving  only  anatomy,  physio- 
logy, and  practice  of  medicine  to  himself.  As  a  result 
we  have  every  department  worked  up  to  the  latest 
date  and  in  a  refreshingly  concise  and  lucid  manner. 
There  are  an  immense  amount  of  illustrations  scat- 
tered throughout  the  work,  and  although  they  have 
often  been  seen  before  iu  the  various  works  upon  gen- 
eral and  special  subjects,  yet  they  will  be  none  the 


J  UDLO  W  [J.  L.),  M.  D., 

A   MANUAL   OF   EXAMINATIONS   upon   Anatomy,   Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royaA 
12mo.  volume  of  816  large  pages,  extra  cloth,  $3  25;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suH- 
able  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


rPANNER  [THOMAS  HA  WKES),  M.  D.,  §r. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOBIS.  Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
<fcc.  In  one  neat  volume  small  12mo.,  of  about  375  pages,  extracloth.  $150.  {Noto  Ready.) 
This  favorite  little  work  h.ts  remained  out  of  print  for  some  years  in  consequence  of  the  pressing 
engagements  which  have  prevented  the  author  from  giving  it  the  thorough  revision  which  it  re- 
quired.  The  great  advance  which  has  taken  place  of  late  in  the  means  and  appliances  for 
observation  and  diagnosis  has  necessitated  a  very  considerable  enlargement  of  the  work,  so  that 
it  now  contains  about  one-half  more  matter  than  the  last  edition.  The  Laryngoscope,  Ophthalmo- 
scope, Sphygmograph,  and  Thermometer  have  received  special  attention.  The  chapter  on  the 
diagnostic  indications  afforded  by  the  Urine  has  been  much  enlarged,  and  a  section  has  been 
inserted  on  the  administration  of  Chloroform.  Special  attention  has  been  given  to  the  medical 
anatomy  of  regions  and  organs,  and  much  has  been  introduced  relative  to  pericardial,  endocurdial, 
abdominal,  and  cerebro-spinal  di.=eases.  On  every  subject  coming  within  its  scope  such  additions 
have  been  made  as  seemed  essential  to  bring  the  book  on  a  level  with  the  most  advan^el  c<m.li- 
tion  of  medical  knowledge  ;  and  it  is  hoped  that  it  will  continue  to  merit  the  very  great  fav^r 
with  which  it  has  hitherto  been  received. 


Henry  C.  Lea's  Publications — {Anatomy). 


QRAY  (HENRY),  F.R.S., 

Lecturer  on  Anntnmy  at  St.  George^ s  Bofspital,  Lnndnn. 

ANATOMY,    DESCRIPTIVE    AND    SURGICAL.      The  Drawinsrs  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.     A  new  American,  from  the  fifth  enlarged 
and  improved  Lonikm  edition.     In  one  magnificent  imperial  octavo  volume,  of  nearly  i'OO 
pages,  with  466  large  and  elaborate  engravings  on  wood.     Price  in  extra  cloth,  $6  00; 
leather,  raised  bands,  $7  00.     (Jt/st  Beady.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  nece.?sary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
fio-ures  of  reference,  with  descriptions  at  the  foot.     They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  its  exceedingly  low  price,  the  work  will  be  found,  in  every  detail  of  mechanical 
execution,  one  of  the  handsomest  that  has  yet  been  offered  to  the  American  profession  ;  while  the 
careful  scrutiny  of  a  competent  anatomist  has  relieved  it  of  whatever  typographical  errors  existed 
in  the  English  edition.     A  few  notices  of  previous  editions  are  subjoined. 


Thus  it  is  that  book  after  book  makes  the  labor  of 
the  studeat  easier  than  before,  ttud  since  we  have 
seen  Blanchard  &  Lea's  new  edition  of  Gray's  Aua- 
tomy,  certainly  the  finest  work  of  the  kind  now  ex- 
tant, we  would  fain  hope  that  the  bugbear  of  medical 
students  will  lose  half  its  horrors,  and  this  necessary 
foundation  of  physiological  science  will  be  much  fa- 
cilitated and  advanced.— i\^.  0.  Med.  News. 

The  various  points  illustrated  are  marked  directly 
on  the  structure;  that  is,  whether  it  be  muscle,  pro 
cess,  artery,  nerve,  valve,  etc.  etc. — we  say  each  point 
is  distinctly  marked  by  lettered  engravings,  so  that 
the  student  perceives  at  once  each  point  described  as 
readily  as  if  pointed  out  on  the  subject  by  the  de- 
monstrator. Most  of  the  illustrations  are  thus  ren- 
dered exceedingly  satisfactory,  and  to  the  physician 
they  serve  to  refresh  the  memory  with  great  readiness 


and  with  scarce  a  reference  to  the  printed  text.  The 
surgical  application  of  the  various  regions  is  also  pre- 
sented with  force  and  clearness,  impressing  upon  the 
student  at  each  step  of  his  research  all  the  important 
relaiions  of  the  structure  demonstrated. — Cincinnoii 
Lancet. 

This  is,  we  believe,  the  handsomest  book  on  Aaa- 
tomy  as  yet  published  in  onr  language,  and  bids  fair 
to  become  in  a  short  time  the  standard  text-book  of 
our  colleges  and  studies.  Students  and  practitioners 
will  alike  appreciate  this  book.  We  predict  for  it  a 
bright  career,  and  are  fully  prepared  to  endorse  the 
statement  of  the  London  La7icet,  that  "  We  are  not 
acquainted  with  any  work  in  any  language  which 
can  take  equal  rank  with  the  one  before  us."  Paper, 
priuting,  binding,  all  are  excellent,  and  we  feel  that 
a  grateful  profession  will  not  allow  the  publishers  to 
go  unrewarded. — Nashville  Med.  and  Surg.  Journal. 


OBHTH  {HENRY  H.),  M.D.,         and  JJORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  &c.  Late  Prof,  of  Anatomy  in  the  Univ.  of  Penna.,  &o. 

AN    ANATOMICAL    ATLAS,  illustrative  of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred 

and  fifty  beautiful  figures.     $4  50. 
The  plan  of  this  Atlas,  which  renders  it  so  pecn-  I  the  kind  that  has  yet  appeared;  and  we  must  add, 
liarly  convenient  for  the  student,  and  its  superb  ar-  |  the  very  beautiful  manner  in  which  it  is  "got  up  " 
ti^'tical  execution,  have  been  alre;idyp'>inted  out.  We    is  so  creditable  to  the  country  as  to  be  tlatlering  to 
must  congratulate  the  student  upon  the  completion     our  national  pride. —Ame7-ioan  MedicalJournal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 


H 


ARTSHORNE  {HENRY),  M.  D., 

Professor  of  Hygiene,  etc.,  in  the  University  of  Pennsylvania. 

A  HAND-BOOK   OF  HUMAN    ANATOMY  AND   PHYSIOLOPxY, 

for  the  use  of  Students,  with  176  illustrations.     In  one  volume,  royal  12mo.  of  .312  pages; 
extra  cloth,  $1  75.      {Now  Ready.) 


QHARPEY  (  WILLIAM),  M.D.,      and       Q  CAIN  {JONES  §•  RICHARD). 
HUMAN  ANATOMY.   Revised,  with  Notes  and  Additions,  b}-  Joseph 

Lkidy,  M.D.,  Profe.ssor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  i;H(ld  pages,  with  611  illustrations;  extra  cloth,  $6  00. 
The  very  low  price  of  this  stand.ird  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


ALLEN  {J.  M.),  M.D 
THE  PRACTICAL  ANATOMIST;  or.  The  Student's  Guide  in  the 

Dissecting  Room.     With  266  illustrations.     In  one  very  handsome  royal  12mo   volume, 
of  over  600  pages;  extra  cloth,  $2  00. 
One  of  the  most  useful  works  upon  the  subject  ever  written. — Medical  Examiner. 


Henry  C.  Lea's  Publications — (Anatomy). 


|^/L5<9iV  [ERASMUS],  F.R.S. 
A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.    A  new 

and  revised  American,  from  the  lat^t  and  enlarged  English  edition.     Edited  by  W.  H.  Go- 
BRECHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of  Ohio. 
Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.     In  one  large  and 
handsome  octavo  volume,  of  over  liOO  large  pages;  extra  cloth,  $4  00;  leather,  $5  00. 
The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition.     Besides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy.    The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that 
thi'  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  size.     The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

or  THE  SAME  AUTHOR. 

THE  DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Ana- 
tomy. Third  American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and 
rearranged  by  William  Hunt,  M.  D.,  late  Demonstrator  of  Anatomy  in  the  University  of 
Pennsylvania.  In  one  large  and  handsome  royal  12mo.  volume,  of  682  pages^  with  154 
illustrations;  extra  cloth,     $2  00. 

fJEATH  [CHRISTOPHER],  F.  R.  C.  S., 

-'-'-  Teacher  of  Ofjerative  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:    A   Manual   of  Dissections.     From   the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  \V.  Kt;i;,'<, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  .Medical  College,  Philadeipiiia. 
In  ope  handsome  royal  12mo.  volume  of  578  pages,  with  247  illustrations.  Extra  cioth, 
$3  50;  leather,  $4  00.     {J list  Ready.) 

TTODGES,  [RICHARD  M.),  M.D., 

-*-*  Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University. 

PRACTICAL  DISSECTIONS.     Second  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00.  {Just  Issued.) 
The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  course  of  dissections.  The  author  ha« 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subject  in  the  form  which  many  years' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 

-MAC USE  [JOSEPH). 

SURGICAL   ANATOMY.     By  Joseph  Maclise,  Snrgeon.    In  one 

volume,  very  large  imperial  quarto ;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  of  life;  together 
with  copious  explanatory  letter-press       Strongly  and  handsomely  bound  in  extra  cloth. 
Price  $14  00. 
As  no  complete  work  of  the  kind  has  heretofore  been  published  in  the  English  language,  the 
present  volume  will  supply  a  want  long  felt  in  this  country  of  an  accurate  and  comprehensive 
Atlas  of  Surgical  Anatomy,  to  which  the  student  and  practitioner  can  at  all  times  refer  to  ascer- 
tain the  exact  relative  positions  of  the  various  portions  of  the  human  frame  towards  each  other 
and  to  the  surface,  as  well  as  their  abnormal  deviations.     Notwithstanding  the  large  size,  beauty 
and  finish  of  the  very  numerous  illustrations,  it  will  be  observed  that  the  price  is  so  low  as  to 
place  it  within  the  reach  of  all  members  of  the  profession. 

We  know  of  no  work  on  surgical  anatomy  which    refreshed   by  those   clear  and  distinct  dissections, 


can  compete  with  It. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  library  of  any  medical  man,  while  the 
student  could  scarcely  make  a  better  investment  than 
this.— r^e  Western  Journal  of  Medicine  and  Surgery. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given.  While 
the  operator  is  sliown  every  vessel  and  nerve  where 
an  operation  is  contemplated,  the  exact  anatomist  is 


which  every  one  must  appreciate  who  has  a  particle 
of  enthusiasm.  The  English  medical  press  hat  4ujte 
exhausted  the  words  of  jiraise,  in  lecoramending  this 
admirable  treatise.  Those  who  have  any  curiosity 
to  gratify,  in  reference  to  the  perfectibility  of  the 
lithographic  art  in  delineating  the  complex  merlian- 
ism  of  the  human  body,  are  invited  to  examine  onr 
specimen  copy.  If  anything  will  induce  surgeons 
and  students  to  patronize  a  book  of  such  rare  value 
and  everyday  importance  to  them,  it  will  be  a  survey 
of  the  artisti'cal  skill  exhibited  in  these  fac-similes  of 
nature— B<'.«t()»  Med.  and  Surg.  Journal. 


HORNER'S  SPECIAL  .\N.\TOJIY  AND  HISTOLOGY.  I      In  2  vols.  8vo  ,  of  over  1000  pages,  with  more  than 
Eighth  edition,  extensively  revised  and  modified.  |      300  woodcuts  ;  extra  cloth,    6  00 


Henry  C.  Lea's  Publications — (Physiology). 


IXTARSHALL  {JOHN),  F.  R.  S. 

•*■'■*-  Professor  of  Surgery  in  University  College,  London,  &c. 

OUTLINES  OF  PHYSIOLOGY,  HUMAN  AND  COMPARATIVE. 

With  Additions  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  Ac.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pag#s,  extra  cloth,  $6  60 ;  leather,  rai.sed  bands 
$7  60.      (Just  Issued.) 

ern  physiological  science,  both  hnman  and  compara- 
tive, with  which  we  are  acquainted.  To  speak  of 
this  work  in  the  terms  ordinarily  used  on  such  occa- 
sions would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  to  its  author.  To  write  such  a  book 
requires  a  varied  and  wide  range  of  knowledge,  con- 
siderable power  of  analysis,  correct  judgment,  skill 
in  arrangement,  and  conscientious  spirit.  It  must 
have  entailed  great  labor,  but  now  that  the  task  has 
been  fuldUed,  the  book  will  prove  not  only  invaluable 
to  the  student  of  medicine  and  surgery,  but  service- 
able to  all  candidates  in  natural  .science  examinations, 
to  teachers  in  schools,  and  to  the  lover  of  nature  gentv- 
rally.  In  conclusion,  we  can  only  express  the  con- 
viction that  the  merits  of  the  work  will  command  for 
it  that  success  which  tlie  ability  and  vast  labor  dis- 
played in  its  production  so  well  deserve. — London 
Lancet,  Feb.  2-2,  1868. 

If  the  possession  of  knowledge,  and  peculiar  apti- 
tude and  skill  in  expounding  it,  qualify  a  man  to 
write  an  educational  work,  Mr.  Marshall's  treatise 
might  be  reviewed  favorably  without  even  opening 
the  covers.  There  are  few,  if  any,  more  accomplished 
anatomists  and  physiologists  than  the  distinguished 
professor  of  surgery  at  University  College;  and  he 
has  long  enjoyed  the  highest  reputation  as  a  teacher 
of  physiology,  possessing  remarkable  powers  of  clear 
exposition  and  graphic  illustration.  We  have  rarely 
the  pleasure  of  being  able  to  recommend  a  text-book 
so  unreservedly  as  this. — British  Med.  Journal,  Jau. 
2.5,  1868. 


In  fact,  in  every  respect,  Mr.  Marshall  has  present- 
ed us  with  a  most  complete,  reliable,  and  scientific 
work,  and  we  feel  that  it  is  worthy  our  warmest 
commendation. — St.  Louis  Mtd.  Reporter,  Jan.  1S69. 

This  is  an  elaborate  and  carefully  prepared  digest 
of  human  and  comparative  physiology,  designed  for 
the  u.se  of  general  readers,  but  more  especially  ser- 
viceable to  the  student  of  medicine.  Its  style  is  con- 
cise, clear,  and  scholarly;  its  order  perspicuous  and 
exact,  and  its  range  of  topics  extended.  The  author 
and  his  American  editor  have  been  careful  to  bring 
to  the  illustration  of  the  subject  the  important  disco- 
veries of  modern  science  in  the  various  cognate  de- 
partm<-uts  of  investigation  This  is  especially  visible 
iu  the  variety  of  interesting  information  derived  from 
the  Jei.artments  of  chemistry  and  physics.  The  great 
amount  and  variety  of  matter  contained  in  the  work 
is  strikingly  illustrated  by  turning  over  the  copious 
index,  covering  twenty-four  closely  printed  pages  in 
double  columns — Silhnian's  Jotirnal,  Jan.  1869. 

We  doubt  if  there  is  in  the  English  language  any 
compead  of  physiology  more  useful  to  the  student 
than  this  work. — St.  Louis  Med.  ahd  Surg.  Journal, 
Jan.  1S69. 

It  quite  fulfils,  in  our  opinion,  the  author's  design 
of  making  it  truly  c'^jfcafiOTiaiihits  character — which 
is,  perhaps,  the  higliest  commendation  that  can  be 
asked. — Am.  Journ.  Med.  Sciences,  Jan.  1869. 

We  may  now  congratulate  him  on  having  com- 
pleted the  latest  as  well  as  the  best  summary  of  mod- 


rfARPENTER  {WILLIAM  B.),  M.D.,  F.R.S., 

V>'  Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 
cations to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  Ac.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed;  extra  cloth,  $5  60  ;  leather,  raised 
bands,  $6  50. 

We  doubt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. — Virginia  Medical  Journal. 


With  Dr.  Smith,  we  confidently  believe  "that  the 
present  will  more  ihan  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language."  We  know  of  none 
from  the  pages  of  which  a  satisfactory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  np  the  study  of  physiology  in  its  reference  tof 
the  institutes  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences. 


The  above  is  the  title  of  what  is  emphatically  the 
great  work  on  physiology ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  authority. — Atlanta  lied. 
Journal. 


JOY  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIYE  PHYSIOLOGY.    New  Ameri- 

can,  from  the  Fourth  and  Revised  London  Edition.     In  one  large  and  handsome  octavo 
vohnne,  with  over  three  hundred  beautiful  illustrations      Pp.  762.    Extra  cloth,  $6  00. 
As  a  complete  and  condensed  treatise  on  its  extended  and  important  .subject,  this  work  becomes 

a  neces.sity  to  student.*  of  natural  science,  while  the  very  lovr  price  at  which  it  is  offered  places  it 

within  the  reach  of  all. 


J^IRKES  {WILLIAM  SENHOUSE),  31. D., 

A  MANUAL  OF  PHYSIOLOGY.     A  new  American  from  the  third 

and  improved  London  edition      With  two  hundred  illustrations.     In  one  large  and  hand- 
some royal  l2mo.  volume.     Pp.  686.     Extra  cloth,  $2  25  ;  leather,  $2  75. 
It  is  at  once  convenient  in  size,  comprehensive  in  |  lent  guide  in  the  study  of  physiology  in  its  most  ad- 


design,  and  concise  in  statement,  and  altogether  well 
adapted  for  the  purpose  de.signeJ. — St.  Louis  Me'l. 
and  Surg,  -fournal. 

The  physiological  reader  will  llnd  U  a  inost  excel- 


vauced  and  perfect  form.  The  author  has  shown 
himself  capable  of  giving  details  sutflciently  ample 
in  a  Condensed  and  eoueeutraied  shape,  on  a  science 
in  which  it  is  necessary  at  once  to  be  correct  and  not 
lengthened — Edinburgh  Med.  and  Surg  Journal. 


Henry  C.  Lea's  Publications — (Physiology). 


T)ALTOy  {J.  C),  M.  D., 

-'-^  Professor  of  Physiokigy  in  the  College  of  Physicians  and  Surgeons,  New  York,  <tc. 

A  TREATISE  ON  HUMAX  PHYSIOLOGY.    Designed  for  the  use 

of  Students  ^ud  Practitioners  of  Medicine.  Fourth  edition,  revised,  with  nearly  three  hun- 
dred illustrations  on  wood.  In  one  veiy  beautiful  octavo  volume,  of  about  700  pages,  extra 
cloth,  $5  25  i  leather,  $6  25.     {Just  Issued.) 

From  the  Preface  to  the.  Neto  Edition. 
"The  progress  made  by  Physiology  and  the  kindred  Sciences  during  the  last  few  years  has  re- 
quired, for  the  present  edition  of  this  work,  a  thorough  and  extensive  revision.  This  progress 
has  not  consisted  in  any  very  striking  single  discoveries,  nor  in  a  decided  revolution  in  any  of 
the  departments  of  Physiology ;  but  it  has  been  marked  by  great  activity  of  investigation  in  a 
multitude  of  different  directions,  the  combined  results  of  which  have  not  failed  to  impress  a  new 
character  on  many  of  the  features  of  physiological  knowledge.  ...  In  the  revision  and 
correction  of  the  present  edition,  the  author  has  endeavored  to  incorporate  all  such  improve- 
ments in  physiological  knowledge  with  the  mass  of  the  text  in  such  a  manner  as  not  essentially 
to  alter  the  structure  and  plan  of  the  work,  so  far  as  they  have  been  found  adapted  to  the  wants 
and  convenience  of  the  reader.  .  .  .  Several  new  illustrations  are  introduced,  some  of  them 
as  additions,  others  as  improvements  or  corrections  of  the  old.  Although  all  parts  of  the  book 
have  received  more  or  less  complete  revision,  the  greatest  number  of  additions  and  changes  were 
required  in  the  Second  Section,  on  the  Physiology' of  the  Nervous  System." 

The  advent  of  the  first  editiou  of  Prof.  Daltoa's 
Physiology,  about  eight  years  ago,  marked  a  new  era 
in  the  study  of  physiology  to  the  American  student. 
Under   Dalton'g  skilful  management,  physiological 


science  threw  off  the  long,  loose,  ungainly  garments 
of  probability  and  surmise,  in  which  it  had  been  ar- 
rayed by  most  artists,  and  came  among  us  smiling 
and  attractive,  in  the  beautifully  tinted  and  closely 
fitting  dress  of  a  demonstrated  science.  It  was  a 
stroke  of  genius,  as  well  as  a  result  of  erudition  and  !  commendation.    Ever  since  its  first  appearance  it  has 


merits  of  clearness  and  condensation,  and  being  fully 
brought  up  to  the  present  level  of  Physiology,  it  is 
undoubtedly  one  of  the  most  reliable  text-books 
upon  this  science  that  could  be  pla'""l  in  the  hands 
of  the  medical  student. — A'm.  Journal  Med.  Scie-nces, 
Oct.  1867. 

Prof.  Dalton's  work  has  such  a  well-established 
reputation  that  it  does  not  stand  in  need  of  any  re- 


talent,  that  led  Prof.  Daltou  to  present  to  the  world 
a  work  on  physiology  at  once  brief,  pointed,  and  com- 
preheusive,  and  which  exhibited  plaiuly  in  letter  and 
drawings  the  basis  upon  which  the  conclusions  ar- 
rived at  rested.  It  is  no  disparagement  of  the  many 
excellent  works  on  physiology,  published  prior  to 
that  of  Dalton,  to  say  that  none  of  them,  either  in 
plaa  of  arrangement  or  clearness  of  execution,  could 
be  compared  with  his  for  the  use  of  students  or  gene- 
ral practitioners  of  medicine.  For  this  purpose  his 
book  has  no  equal  in  the  English  language. —  Western 
Journal  of  Medicine,  Nov.  1867. 

A  capital  text-book  in  every  way.  We  are,  there- 
fore, glad  to  see  it  in  its  fourth  edition.  It  has  already 
been  examined  at  full  length  in  these  columns,  so  that 
we  need  not  now  further  advert  to  it  beyond  remark- 
ing that  both  revision  and  enlargement  have  been 
most  judicious. — London  Med.  Times  and  Gazette, 
Oct.  19,  1667. 

No  better  proof  of  the  value  of  this  admirable 
work  could  be  produced  than  the  fact  that  it  has  al-  ] 
ready  reached  a  fourth  edition  in  the  short  space  of  |  Sept.  18(57 
eight  years.    Possessing  ia  an  eminent  degree  the 


become  the  highest  authority  in  the  Engli.sh  language; 
and  that  it  is  able  to  maintain  the  enviable  positioa 
which  it  has  taken,  the  rapid  exhaustion  of  the  dif- 
ferent successive  editions  is  sufficient  evidence.  The 
present  edition,  which  is  the  fourth,  has  been  tho- 
roughly revised,  and  enlarged  by  the  Incorporation 
of  all  the  many  important  advances  which  have 
lately  been  made  in  this  rapidly  progressing  science. 
—N.  T.  Med.  Record,  Oct.  15,  1867. 

As  it  stands,  we  esteem  it  the  very  best  of  the  phy- 
siological text-books  for  the  student,  and  the  most 
concise  reference  and  guide-book  for  the  practitioner. 
~^.  Y.  Med.  Journal,  Oct.  1867. 

The  present  edition  of  this  now  standard  work  fully 
sustains  the  high  reputation  of  its  accomplished  au- 
thor. It  is  not  merely  a  reprint,  but  has  been  faith- 
fully revised,  and  enriched  by  such  additious  a«  the 
progress  of  physiology  has  rendered  desirable  Taken 
as  a  whole,  it  is  unquestionably  the  moot  reliable  and 
useful  treatise  on  the  subject  thnt  has  been  issued 
from  the  American  press. — Chicago  Med.  Juuraul, 


TiUNGLISON  (ROBLEY),  M.D., 

•M^  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  OolUge,  Philadelphia. 

HUMAN  PHYSIOLOGY.    Eighth  edition.     Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  extra  cloth.     $7  00. 

T  EHMANN  [G.  G.) 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  George  E.  Day,  M.  D.,  F.  R.  S.,  Ac.,  edited  by  R.  E.  Rogers,  M.  D.,  Profe.ssor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  extra  cloth.     $6  00. 

T>T  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.    Translated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl- 
vania.  With  illustrations  on  wood.  In  one  very  handsome  octavo  volume  of  336  pages 
extra  cloth.     $2  25. 

fpODD  {ROBERT  B.),  M. D.  F.R.S.,  and  ^0  WMAN  ( W.),  F. R. S. 
THE    PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY   OF 

MAN.  With  about  three  hundred  large  and  beautiful  illustrations  on  wood.  Complete  in 
one  large  octavo  volume  of  950  pages,  extra  cloth.     Price  $4  75. 


10 


Henry  C.  Lea's  Publications — {Chemistry). 


-nRANDE  (  WM.  T.),  D.  C.L.,  and   JIAYLOR  {ALFRED  S.),  M.D.,  F.R.S. 
CHEMISTRY.     Second  American  edition,  thoroughly  revised  by  T>r. 

Taylor.     In  one  hJindsome  8vo.  Volunae  of  764  pages,  extra  cloth,  $5  00  ;  leather,  $6  00. 
(Lately  Issued.)  ■ 

From  Dr.  Taylor  s  Preface. 

"The  reviaion  of  the  second  edition,  in  consequence  of  the  death  of  my  lamented  colleague, 
has  devolved  entirely  upon  myself.  Every  chnpter,  and  indeed  every  page,  has  been  revised, 
and  numerous  additions  made  in  all  parts  of  the  volume.  These  additions  have  been  restricted 
chiefly  to  subjects  having  some  practical  interest,  and  they  have  been  made  as  concise  as  possible, 
in  order  to  keep  the  book  within  those  limits  which  may  retain  for  it  the  character  of  a  Student's 
Manual  ''—London,  June  29,  1867. 

A  book  that  has  already  so  established  a  repnta-  '  This  second  American  edition  of  an  excellent  trea- 
tion,  as  has  Brande  and- Taylor's  Chemistry,  can  tise  on  chemical  science  is  not  a  mere  republication 
hiiidly  need  a  notice,  save  to  mention  the  additions  from  the  English  press,  bnt  is  a  revision  and  en- 
and  improvements  of  the  edition.  Doubtless  the  largement  of  the  original,  under  the  supervision  of 
■W'Tk  will  long  remain  a  favorite  text-book  in  the  ihe  surviving  author.  Dr.  Taylor.  The  favorable 
school:',  as  well  as  a  convenient  book  of  reference  for  opinion  expressed  on  the  publication  of  the  former 
all.— jv!  Y.  Medical  Gazette,  Oct.  12,  1867.  !  edition  of  this  work  is  fully  sustained  by  the  present 

revision.  In  which  Dr.  T.  has  increased  the  size  of 

For  this  reason  we  hail  with  delight  the  Tepnblica-  ;  the  volume,  by  an  addition  of  sixty-eight  pages.— .ilm. 
tion,  in  a  form  which  will  meet  with  general  approval  |  jQ^im.  Med.  Sciences,  Oct.  1S67. 

and  copimand  public  attention,  of  this  really  valna-  WivnnnoK  im  Crfmi^^trt  op  tup  STrnps-r  — 

hie  standard  work  on  chemistry— more  particularly  :  ^  ^he  Handbook  in  I^hemistrt  of  the  feTrnBNT.— 
as  it  has  been  adapted  with  such  care  to  the  wants  of  Fo>-  c  earness  of  language,  accuracy  of  description, 
the  Leneral  public  The  well  known  scholarship  of  extent  of  information  and  freedom  from  pedantry 
ts  authors,  and  their  extensive  researches  for  many  and  mysticism  no  other  text-book  comes  into  corn- 
years  in  experimental  chemistry,  have  been  long  ap-    Vetnion  with  it.-The  Lancet. 

preciatedinthescientific  world,  but  in  this  work  they  The  authors  set  out  with  the  definite  purpose  of 
have  been  careful  to  give  the  largest  possible  amount  writing  a  book  which  shall  be  intelligible  to  any 
of  information  with  the  most  sparing  use  of  technical  educated  man.  Thus  conceived,  and  worked  out  in 
terras  and  phraseology,  so  as  to  furnish  the  reader,  the  most  sturdy,  common-sense  method,  this  book 
"whether  a  student  of  medicine,  or  a  man  of  the  gives  in  the  clearest  and  most  summary  method 
world,  with  a  plain  introduction  to  the  science  and  possible  all  the  facts  and  doctrines  of  chemistry.— 
jjractice  of  chemistry." — Journal  of  Applied  Chem-  Medical  Times. 
istry,  Oct.  1S67. 

DLING{W1LLIA3T), 

Lecturer  on  Chemistry,  at  St.  Bartholomew's  Ilo.spitul,  i-e. 

A  COURSE  OF  PRACTICAX  CHEMISTRY,  arranged  for  the  Vse 

of  Medical  Students.    With  Illustrations.    From  the  Fourth  and  Revised  London  Edition. 

In  one  neat  royal  12mo.  volume,  extra  cloth.  $2.  {Just  Jssved.) 
Asa  work  for  the  practitioner  it  cannot  be  excellwl 
It  is  written  plainly  and  concisely,  andgivesina  very 
small  compass  the  information  required  by  the  busy 
piactitioner.  It  is  essentially  a  work  for  the  physi- 
cian, and  no  one  who  purchases  it  will  ever  regret  the 
outlay.  In  addition  to  all  that  is  usually  given  in 
coi^nection  with  inorganic  chemistry,  there  are  most 
valuable  contributions  to  toxicology,  animal  and  or- 


0 


gauic  chemi.^try,  etc.  The  portion.s  devoted  to  a  dis- 
cussion of  these  subjects  are  very  excellent.  In  no 
work  can  the  physician  find  more  thai  is  valuable 
and  reliifble  in  regard  to  mine,  bile,  milk,  bone,  uri- 
nary calculi,  tissue  composition,  etc.  The  work  is 
small,  reasonable  in  price,  and  well  published. — 
Richmond  and  Louisville  Med.  Journal,  Dec.  1S69. 


jyOWMAN  {JOHN  E.),M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.  Fifth 
American,  from  the  fourth  and  revised  English  Edition.  In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  extra  cloth.     $2  25.     (Now  Ready.)  , 

The  fourth  edition  ofi  this  invaluable  text-book  of 
Medical  Chemistry  was  published  in  England  in  'Octo- 
ber of  the  last  year.  The  Editor  has  brouaht  down 
the  Handbook  to  that  date,  introducing, as  faraswiis 
compatible  with  the  necessary  conci-seness  of  such  a 
work,  all  the  valuable  discoveries  in  the  science 
f>Y  THE  SAME  AUTHOR.  

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Fifth  American,  from  the  fifth  and  revised  London  edition.  With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  extra  cloth.     $2  26.     (Now  Ready.) 


which  have  come  to  light  since  the  previous  edition 
was  printed.  The  work  is  indispensable  to  pvpry 
student  of  medicine  or  enlightened  practitioner.  It 
is  printed  in  cU-ar  type,  and  the  illiisirations  are 
numerous  and  intelligible. — Boston  Mtd.  and  Snrg. 
Journal. 


One  of  the  most  complete  manuals  that  has  for  a 
long  time  been  given  to  the  medical  student. — 
Athen(Bum. 

We  regard  it  as  realizing  almost  everything  to  be 
desired  in  an  introduction  to  Practical  Chemistry. 


It  is  by  far  the  best  adapted  for  the  Chemical  student 
of  any  that  has  yet  fallen  iu  our  way. — British  and 
Foreign  Medico-'Ohirurgical  Revieio. 

The  best  iutrodnetory  work  on  the  subject  with 
which  we  are  acquainted. — Edinburgh  Monthly  Jour. 


(IRAHAM  {THOMAS),  F.R.S. 

THE   ELEMENTS  OF  INORGANIC  CHEMISTRY,  including  the 

Applications  of  the  Science  in  the  Arts.  New  and  much  enlarged  edition,  by  Henry 
Watts  and  Robert  Bridges,  M.  D.  Complete  in  one  large  andhandsoiue  octavo  volume, 
of  over  800  very  large  pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth. 
$5  50. 


KNAPPS  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  Wilh  American 
additions,  by  Prof.  Walter  R.  Johnson.    In  two 


very  handsome  octavo  volumes,  with  500  wood 
engravings,  extra  cloth,  ^ij  00, 


Henry  C.  Lea's  Publications — {ChemiHtrxj^  Pharmacy, ((;c.).      11 


JprOWNES  {GEORGE},  Ph.  D. 


A  MANUAL  OP  ELEMENTARY  CHEMISTRY;   Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  A  new  American,  from  the 
tenth  and  revised  London  edition.  Edited  by  Robert  Bridges.  M.  D.  In  one  lari^e 
royal  12mo.  volume,  of  about  860  pp  ,  extra  cloth,  *2  75  ;  leather,  S.'?  2.5.  (Ji/xt  Issitfd^ 
Some  years  having  elapsed  since  the  appearance  of  the  last  American  edition,  and  several 
revisions  having  been  made  of  the  work  in  England  during  the  interval,  it  will  be  found  very 
greatly  altered,  and  enlarged  by  about  two  hun  Ired  and  fifty  pages,  containing  nearly  one  half 
more  matter  than  before.  The  editors,  Mr.  Watts  and  Dr.  Bence  Jones,  have  labored  sedulously 
to  render  it  worthy  in  all  respects  of  the  very  remarkable  favor  which  it  has  thus  far  enjoyed,  by 
incorporating  in  it  all  the  most  recent  investigations  and  discoveries,  in  so  far  as  is  compatible  with 
its  design  as  an  elementary  text-book.  While  its  distinguishing  ch.iracteristics  have  been  pre- 
served, various  portions  have  been  rewritten,  and  especial  pains  have  been  taken  with  the 
department  of  Organic  Chemistry  in  which  late  researches  have  accumulated  so  many  new  facts 
and  have  enabled  the  subject  to  be  systematized  and  rendered  intelligible  in  a  manner  formerly 
impossible.  As  only  a  few  months  have  ehipsed  since  the  work  thus  p:issed  through  the  ban  Is 
of  Mr.  W.itts  and  Dr.  Bence  Jones,  but  little  has  remained  to  be  done  by  the  American  editor. 
Such  additions  as  seemed  advisable  have  however  been  made,  and  especial  care  has  been  taken 
to  secure,  by  the  closest  scrutiny,  the  accuracy  so  essential  in  a  work  of  thi-i  nature. 

Thus  fully  brought  up  to  a  level  with  the  latest  advances  of  science,  and  presented  at  a  price 
within  the  reach  of  all,  it  is  hoped  that  the  work  will  maintain  its  position  as  the  favorite  text- 
book of  the  medical  student. 


This  work  is  so  well  kuowa  that  it  eeems  almost 
superlluous  for  us  to  speak  about  it.  It  has  been  a 
favorite  text-book  with  medical  stuJeuts  fur  years, 
and  Its  popularity  has  iu  no  respect  dimini'shed. 
Whenever  we  have  been  cousuUed  by  medical  stu- 
dents, as  has  frequently  occuired,  what  treatise  on 
chemistry  they  should  procure,  we  have  always  re- 
commeudrd  Fownes',  for  we  regarded  it  as  the  best. 
There  is  no  work  that  combines  so  many  excelleu- 
ces.  It  is  of  convenient  size,  not  prolix,  of  plain 
perspicuous  diction,  contains  all  the  most  recent 
discoveries,  and  is  of  moderate  price. — Gincinnati 
Med. Repertory,  Aug.  1S69. 

Large  additions  have  been  made,  especially  in  the 
department  of  organic  chemistry,  and  we  know  of  no 
other  work  that  has  greater  claims  on  the  physician, 
pharmaceutist,  or  student,  than  this.  We  cheerfully 
recommend  it  as  the  best  text-book  on  elementary 
chemistry,  and  bespeak  for  it  the  careful  attention 
of  students  of  pharmacy. — Ohicago  Pliarmaeist,  Aug. 
1869. 

The  American  reprint  of  the  tenth  revised  and  cor- 
rected Euglish  edition  is  now  issued,  and  represents 
the  present  condition  of  the  science.  No  comments 
are  necessary  to  insure  it  a  favorable  reception  at 
the  hands  of  practitioners  and  students.  —  Boston 
Med.  and  Surg.  Journal,  Aug.  12,  1S69. 

It  will  continue,  as  heretofore,  to  hold  the  first  rank 
as  a  text-book  for  students  of  medicine. — Chicago 
Med.  Examiner,  Aug.  1869. 

,  This  work,  long  the  recognized  Manual  of  Chemistry, 
appears  as  a  tenth  edition,  under  the  able  editorship 
of  Bence  Jones  and  Henry  Watts.     The  chapter  on 


the  General  Principles  of  Chemical  Philosophy,  and 
the  greater  part  of  the  organic  chemistry,  have  hfpa 
rewritten,  and  the  whole  work  revised  in  accordance 
with  the  recent  advances  in  clieraical  knowledge.  It 
remains  the  standard  text-hook  of  chemistry. — Dub- 
lin Quarterly  ./nuriial,  Feb.  1869. 

There  is  probably  not  a  student  of  chemistry  in  this 
country  to  whom  the  admirable  manual  of  the  late 
Profe.ssor  Fownes  is  nftknown  It  has  achievpd  a 
success  which  we  believe  is  entirely  without  a  paral- 
lel among  scientific  text-books  in  our  language.  This 
success  has  arisen  from  the  fact  that  there  is  no  En- 
glish work  on  chemistry  which  combines  so  many 
excellences.  Of  convenient  size,  of  attractive  form, 
clear  and  concise,  in  diction,  well  illustrated,  and  of 
moderate  price,  it  would  seem  that  every  requisite 
for  a  student's  haud-bonk  has  been  attained.  The 
ninth  edition  was  published  under  the  joint  editor- 
ship of  Dr.  Bence  Jones  and  Dr.  Hofraann;  the  new 
one  has  been  superintended  through  the  press  by  Dr. 
Bence  Jones  and  Mr.  Henry  Watts.  It  i«  not  too 
much  to  say  that  it  could  not  possibly  have  been  in 
better  hands.  There  is  no  one  in  England  who  can 
compare  with  Mr.  Watts  in  experience  as  a  compiler 
in  chemical  literature,  and  we  have  much  pleasui* 
in  recording  the  fact  that  his  reputation  is  well  sus- 
tained bv  this,  his  last  undertaking. — T/ie  Clumical 
News,  Fe'b.  1869. 

Here  is  a  new  edition  which  has  been  loog  watched 
for  by  eager  teachers  of  chemistry.  In  its  new  garb, 
and  under  the  editorship  of  Mr.  Watts,  it  has  resumed 
its  old  place  as  the  most  successful  of  text-books.— 
Indian  Medical  Gazette,  Jan.  1,  1869. 


ATTFIELD  {JOHN),  Ph.D. 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  Ac. 

CHEMISTRY,    GENERAL,  MEDICAL,  AND  PHARMACEUTICAL  ; 

Including  the  Chemistry  of  the  British  Pharmacopoeia.     Adapted  to  the  Requirements  of 
American  Practice  of  Medicine  and  Pharmacy.     In  one  handsome  volume.    (Preparing.) 


It  contains  a  most  admirable  digest  of  what  is  spe- 
cially needed  by  the  medical  student  in  all  that  re- 
lates to  practical  chemistry,  and  constitutes  for  him 

a  sound  and  useful  text-book  on  the  subject 

We  commend  it  to  the  notice  of  every  medical,  as  well 
as  pharmaceutical,  student.  We  only  regret  that  we 
had  not  the  book  to  depend  upon  in  working  up  the 
subject  of  practical  and  pharmaceutical  chemistry  for 
the  University  of  London,  for  which  it  seems  to  us 
that  it  is  exactly  adapted.  This  is  paying  the  book  a 
high  compliment. — Tlie  Lancet. 

Dr.  Attfield's  book  is  written  in  a  clear  and  able 
manner;  it  is  a  work  sMi^ewerJ.?  and  without  a  rival ; 
it  will  be  welcomed,  we  think,  by  every  reader  of  the 
'Pharmacopoeia,'  and  is  quite  as  well  suited  for  the 
medical  student  as  for  the  pharmacist. — The  Oliemi- 
ctil  News. 

A  valuable  guide  to  practical  medical  chemistry, 
and  an  admirable  companion  to  the  "BritisTi  Phar- 
.  macopojia  "  It  is  rare  to  find  so  many  qualities  com- 
bined, and  quite  curious  to  note  how  much  valuable 
information  finds  a  mutual  interdependence. — Medi- 
cal Tiriien  and  Gazette. 


It  is  almost  the  only  book  from  which  the  medical 
student  can  work  up  the  pliarmacopojial  ehomi'try 
required  at  his  examinations. — The  Pharmaceutical 
Journal. 

At  page  3.50  of  the  current  volume  of  this  journal, 
we  remarked  that  "  there  is  a  sad  dearth  of  [medical] 
students'  text-books  in  chemistry."  Dr.  Attfield's 
volume,  just  published,  is  rather  a  new  book  than  a 
second  edition  of  his  previous  work,  and  more  nearly 
realizes  our  ideal  than  any  book  we  have  before  seen 
on  the  subject.— T/ie  Briti.'/h  Medical  Journal. 

The  introduction  of  new  matter  has  not  destroyed 
the  original  character  of  the  work,  as  a  treatise  on 
pharmaceutical  and  medical  chemistry,  but  has  sim- 
ply extended  the  foundations  of  these  special  dep;»rt- 
ments  of  the  science.— T/te  Ohemiat  and  Druggist. 

We  believe  that  this  manual  has  beou  already 
adopted  as  the  class-book  by  many  of  the  professors 
in  the  public  schools  throu^out  the  United  Kingdom. 
...  In  pharmaceutical  chemistry  applied  to  the  pliar- 
macoproia,  we  know  of  no  rival.  It  is,  therefore,  p;ir- 
liciilarly  suited  to  the  medical  student. — The  Medical 
Press  and  Circular. 


12       Henry  C.  Lea's  Publications — {Mat.  Med.  and  Therapeutics). 


pARRISH  [ED  WARD), 

Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and 
Prescriptions.     Third  Edition,  greatly  improved.     In  one  handsome  octavo  volume,  of  850 
pages,  with  geveral  hundred  illustrations,  extra  cloth.     $5  00. 
The  immense  amount  of  practical  information  condensed  in  this  volume  may  be  estimated  from 
the  fact  that  the  Index  contains  about  4700  items.      Under  the  bead  of  Acids  there  are  312  refer- 
ences; under  Emplastrum,  36;  Extracts,  159;  Lozenges,  25;  Mixtures,  65;  Pills,  56;  Syrups, 
131;  Tinctures,  138;  Unguentum,  57,  Ac. 


We  have  examined  this  large  volume  with  a  good 
deal  of  care,  and  find  that  the  author  has  completely 
exhausted  the  subject  upon  which  he  treats  ;  a  more 
complete  work,  we  think,  it  would  be  impossible  to 
♦find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ;  indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  par- 
chase  it,  we  feel  sure  the  practical  information  he 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Canada  Med.  Journal,  Nov.  1864. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — San  Francisco  Med.  Press,  July, 
X864. 

When  we  say  that  this  book  is  in  some  respects 
the  best  which  has  been  published  on  the  subject  in 
the  English  language  for  a  great  many  years,  we  do 


not  wish  it  to  be  understood  as  very  extravagant 
praiwe.  In  truth,  it  is  not  so  much  the  best  as  the 
only  book. — The  London  Chemical  News. 

An  attempt  to  furnish  anything  like  an  analysis  of 
Parrish's  very  valuable  and  elaborate  Treatise  on 
Practical  Pharmacy  would  require  more  space  than 
we  have  at  our  disposal.  This,  however,  is  not  so 
mnch  a  matter  of  regret,  inasmuch  as  it  would  be 
difficult  to  think  of  any  point,  however  minute  and 
apparently  trivial,  connected  with  the  manipulation 
of  pharmaceutic  .substances  or  appliances  which  has 
not  been  clearly  and  carefully  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  enlarging  further 
on  this  valuable  work,  and  we  must  conclude  by  a 
simple  expression  of  our  hearty  appreciation  of  its 
merits. — Dublin  Quarterly  Jour,  of  Medical  Science, 
August,  1864. 


OTILLE  {ALFRED),  M.D., 

A^  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Sj^stematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Third  edition,  revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes  of  about 
1700  pages,  extra  cloth,  $10;  leather,  $12.     {Just  Issued.) 


T>r.  Stille's  splendid  work  on  therapeutics  and  ma- 
teria medica. — London  Med.  TiTnes,  April  8,  186.5. 

Dr.  Still6  stands  to-day  one  of  the  best  and  most 
honored  representatives  at  home  and  abroad,  of  Ame- 
rican medicine ;  and  these  volumes,  a  library  in  them- 
selvos,  a  treasure-house  for  every  studious  physician, 
assure  his  fame  even  had  he  done  nothing  more. — The 
Western  Journal  of  Medicine,  Dec.  1868. 

We  regard  this  work  as  the  best  one  on  Materia 
Medica  in  the  English  language,  and  as  such  it  de- 
serves the  favor  it  has  received. — Am.  Journ.  Medi- 
cal Sciences,  July  1868. 

We  need  not  dwell  on  the  merits  of  the  third  edition 
of  this  magnificently  conceived  work.  It  is  the  work 
on  Materia  Medica,  in  which  Therapeutics  are  prima- 
rily con.sidered — the  mere  natural  history  of  drugs 
being  briefly  disposed  of  To  medical  practitioners 
this  is  a  very  valuable  conception.  It  is  wonderful 
how  much  of  the  riches  of  the  literature  of  Materia 
Medica  has  been  condensed  into  this  book.  The  refer- 
ences alone  would  make  it  worth  possessing.  But  it 
is  not  a  mere  compilation.  The  writer  exercises  a 
good  judgment  of  his  own  on  the  great  doctrines  and 
points  of  Therapeutics.  For  purposes  of  practice, 
Stille's  book  is  almost  unique  as  a  repertory  of  in- 
formation, empirical  and  scientific,  on  the  actions  and 
uses  of  medicines. — London  Lancet,  Oct.  31,  1868. 

Through  the  former  editions,  the  professional  world 
is  well  acquainted  with  this  work.     At  home  and 


abroad  its  reputation  as  a  standard  treatise  on  Materia 
Medica  is  securely  established  It  is  second  to  no 
work  on  the  subject  in  the  English  tongue,  and,  in- 
deed, is  decidedly  superior,  in  some  respects,  to  any 
other. — Pacific  Med.  and  Surg.  Journal,  July,  1868. 

Still6's  Therapeutics  is  incomparably  the  best  work 
on  the  subject.— JV.  Y.  Med.  Gazette,  Sept.  26,  1868. 

Dr.  Stmt's  work  is  becoming  the  best  known  of  any 
of  our  treatises  on  Materia  Medica.  .  .  .  One  of  the 
most  valuable  works  in  the  language  on  the  subjects 
of  which  it  treats. — N.  Y.  Med.  Journal,  Oct.  1868. 

The  rapid  exhaustion  of  two  editions  of  Prof.  Stille's 
scholarly  work,  and  the  consequent  necessity  for  a 
third  edition,  is  sufficient  evidence  of  the  high  esti- 
mate placed  upon  it  by  the  profession.  It  is  no  exag- 
geration to  say  that  there  is  no  superior  work  upon 
the  subject  in  the  English  language.  The  present 
edition  is  fully  up  to  the  most  recent  advance  in  the 
science  and  art  of  therapeutics. — Leavenworth  Medi- 
cal Herald,  Aug.  1S68. 

The  work  of  Prof.  Still6  has  rapidly  taken  a  high 
place  in  professional  esteem,  and  to  say  that  a  third 
edition  is  demanded  and  now  appears  before  us,  .sufii- 
ciently  attests  the  firm  position  this  treatise  has  made 
for  itself.  As  a  work  of  great  re.'^earch,  and  scholar- 
ship, it  is  safe  to  say  we  have  nothing  superior.  It  is 
exceedingly  full,  and  the  busy  practitioner  will  tind 
ample  suggestions  upon  almost  every  important  point 
of  therapeutics. — Cincinnati  Lancet,  Aug.  lSt>8. 


G 


RIFFITH  [ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Pre- 

paring  and  Administering  Officinal  and  other  Medicines.     The  whole  adapted  to  Physicians 
and  Pharmaceutists.     Second  edition,  thoroughly  revised,  with  numerous  additions,  by 
Robert  P.  Thomas,  M.D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of 
Pharmacy.     In  one  large  and   handsome  octavo  Tolume  of  650  pages,  double-columns. 
Extra  cloth,  $4  00;  leather,  $5  00. 
Three  complete  and  extended  Indexes  render  the  work  especially  adapted  for  immediate  consul- 
tation.    One,  of  Diseases  and  their  Remedies,  presents  under  the  head  of  each  dise.ase  the 
remedial  agents  which  have  been  usefully  exhibited  in  it,  with  reference  to  the  formulaB  containing 
them — while  another  of  Pharmaceutical  and  Botanical  Names,  and  a  very  thorough  General 
Index  afford  the  means  of  obtaining  at  once  any  information  desired.     The  Formulary  itself  is 
arranged  alphabetically,  under  the  heads  of  the  leading  constituents  of  the  prescriptions. 
We  know  of  none  in  our  language,  or  any  other,  so  comprehensive  in  its  details. — London  Lancet. 
One  of  the  most  complete  works  of  the  kind  in  any  language. — Kdinfmrgh  Med.  ./immal. 
We  are  not  cognizant  of  the  existence  of  a  parallel  work. — London  Med.  Gazette. 


Henry  C.  Lea's  Publications— (3/a/.  3Ied.  and  Therapeutics).      13 


jp  ERE  IRA  {JONATHAN),  M.D.,  F.R.S.  and  L.S. 

MATERIA  MEDICA  AND  THERAPEUTICS;  being  an  Abridg- 
ment of  the  late  Dr.  Pereira's  Elements  of  Materia  Medica,  arranged  in  conformity  wi7h 
the  British  Tharmaeopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Chemists  and 
Druggists,  Medical  and  Pharmaceutical  Students,  Ac.  By  P.  J.  Farre,  M.D.,  Senior 
Physician  to  St.  Bartholomew's  Hospital,  and  London  Editor  of  the  British  Pharma!copoeia ; 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain;  and  by  Robert  WaringTon,  F.R.S. ,  Chemical 
Operator  to  the  Society  of  Apothecaries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood.  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  on©  large  and  handsome  octavo  volume  of  1040  closely 
printed  pages,  with  236  illustrations,  extra  cloth,  $7  00;  leather,  raised  bands,  $8  00. 
{Lately  Published.) 


The  task  of  the  American  editor  has  evidently  been 
no  sinecure,  for  not  only  has  he  given  to  us  all  that 
is  contained  in  the  abridgment  useful  for  our  pur- 
poses, but  by  a  careful  and  judicious  embodiment  of 
over  a  hundred  new  remedies  has  increased  the  size 
of  the  former  work  fully  one-third,  besides  adding 
many  new  illustrations,  some  of  which  are  original. 
We  unhesitatingly  say  that  by  so  doing  he  has  pro- 
portionately increased  the  value,  not  only  of  the  con- 
densed edition,  but  has  extended  the  applicability  of 
the  great  original,  and  has  placed  his  medical  coun- 
trymen under  lasting  obligations  to  him.  The  Ame- 
rican physician  now  has  all  that  is  needed  in  the 
shape  of  a  complete  treatise  on  materia  medica,  and 
the  medical  student  has  a  text-book  which,  for  prac- 
tical utility  and  intrinsic  worth,  stands  unparalleled. 
Although  of  considerable  size,  it  is  none  too  large  for 
the  purposes  for  which  it  has  been  intended,  and  every 
medical  man  should,  in  justice  to  him.self,  spare  a 
place  for  it  upon  his  book-shelf,  resting  assured  that 
the  more  he  consults  it  the  better  he  will  be  satisfied 
of  its  excellence.— .y.  Y.  MeA.  Record,  Nov.  13,  1866. 

It  will  fill  a  place  which  no  other  work  can  occupy 
In  the  library  of  the  physician,  otudeut,  and  apothe- 
cary.— Boston  Med.  and  Surg.  Journal,  Nov.  8,  1866. 

Of  the  many  works  on  Materia  Medica  which  have 
ttppeared  since  the  issuing  of  the  British  Pharmaco- 


poeia, none  will  be  more  acceptable  to  the  student 
and  practitioner  than  the  present.  Pereira's  Materia 
Medica  had  loug  ago  asserted  for  itself  the  position  of 
being  the  most  complete  ^ork  on  the  subject  in  the 
English  language.  But  Its  very  completeness  stood 
in  the  way  of  its  success.  Except  in  the  way  of  refer- 
ence, or  to  those  who  made  a  special  study  of  Materia 
Medica,  Dr.  Pereira's  work  was  too  full,  and  its  pe- 
rusal required  an  amount  of  time  which  few  had  at 
their  disposal.  Dr.  Farre  has  very  j  udiciously  availed 
himself  of  the  opportunity  of  the  pubHcatir>n  of  the 
new  Pharmacopoeia,  by  bringing  out  an  abridged  edi- 
tion of  the  great  work.  This  edition  of  Pereira  is  by 
no  means  a  mere  abridged  re-issue,  butcitntains  ma- 
ny improvements,  both  in  the  descriptive  and  thera- 
peutical departments.  We  can  recommend  it  as  a 
very  excellent  and  reliable  text-book. — Edinburgh 
Med.  Journal,  February,  1866, 

The  reader  cannot  fail  to  be  impressed,  at  a  glance, 
with  the  exceeding  value  of  this  work  as  a  compend 
of  nearly  all  useful  knowledge  on  the  materia  medica. 
We  are  greatly  indebted  to  Professor  Wood  for  his 
adaptation  of  it  to  our  meridian.  Without  his  emen- 
dations and  additions  it  would  lose  much  of  its  value 
to  the  American  student.  With  them  it  is  an  Ameri- 
can book.— Pcrei/fc  Medical  and  Surgical  Journal, 
December,  1866. 


TJLLIS  {BENJAMIN),  M.D. 
THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescriptions 

derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.   Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.    The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.    Twelfth  edi- 
tion, carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.D,    In  one  volume  8vo. 
of  376  pages,  extra  cloth,  $3  00.     {Now  Ready.) 
This  work  has  remained  for  some  time  out  of  print,  owing  to  the  anxious  care  with  which  the 
Editor  has  sought  to  render  the  present  edition  worthy  a  continuance  of  the  very  remarkable 
favor  which  has  carried  the  volume  to  the  unusual  honor  of  a  Twelfth  Edition.     He  has  sedu- 
lously endeavored  to  introduce  in  it  all  new  preparations  and  combinations  deserving  of  confidence, 
besides  adding  two  new  classes,  Antemetics  and  Disinfectants,  with  brief  references  to  the  inhalation 
of  atomized  fluids,  the  nasal  douche  of  Thudichum,  suggestions  upon  the  method  of  hypodermic 
injection,  the  administration  of  anassthetics,  &c.  &c.     To  accommodate  these  numerous  additions, 
he  has  omitted  much  which  the  advance  of  science  has  rendered  obsolete  or  of  minor  importance, 
notwithstanding  which  the  volume  has  been  increased  by  more  than  thirty  pages.     A  new  feature 
will  be  found  in  a  copious  Index  of  Diseases  and  their  remedies,  which  cannot  but  increase  the 
value  of  the  work  as  a  suggestive  book  of  reference  for  the  working  practitioner.    Every  precaution 
has  been  taken  to  secure  the  typographical  accuracy  so  necessary  in  a  work  of  this  nature,  and  it 
is  hoped  that  the  new  edition  will  fully  maintain  the  position  which  "  Ellis'  Formulary''  has 
long  occupied.  . 

PARSON  {JOSEPH),  M.D., 

v-/  Professor  of  Materia  Medica  and  PJiarmacy  in  the  University  of  Pennsylvania,  Ae. 

SYNOPSIS  OF  THE   COURSE   OF   LECTURES   ON  MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.  With  three 
Lectures  on  the  Modus  Operandi  of  Medicines.  Fourth  and  revised  edition,  extra  cloth, 
$3  00.     {Just  Issued.) 

DUNGLISON'S  NEW  REMEDIES,  WITH  F0RMTTLJ5E 
FOR  THEIR  PREPAR.4.TI0.\  AND  ADMINISTRA- 
TION. Seventh  edition,  with  extensive  additions. 
One  vol.  Svo  ,  pp.  770;  extra  cloth.    $100. 

ROYLE'S  MATERIA  MEDICA  AND  THERAPEU- 
TICS. Edited  by  Joseph  Cakson,  M.  D.  With 
ninety-eight  illustrations.  1  vol.  8vo.,  pp.  700,  ex- 
tra cloth.    $:?  00. 

CHRISTISON'S  DISPENSATORY.  With  copious  ad- 
ditions, and  213  large  wood-engravings.  By  R. 
E«LBSPEi,D  Griffith,  M,  D.  One  vol.  Svo.,  pp.  1000 ; 
eztr&  cloth.    $4  00. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liquors  in  Health  awd  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  and 
explanatlonsofscientiflc  words.  In  one  neat  r2mo. 
volume,  pp.  178,  extra  cloth.    60  cents. 

De  JONGH  ON  THE  THREE  KINDS  OF  COD-LIVER 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties.    1  vol.  12ino.,  cloth.     75  cents. 

WAYNE'S  DISPENSATORY  AND  THERAPEUTICAL 
Remembrancer.  Uy  R.  E.  Griffith,  M.  D.  In  one 
12mo.  volume,  300  pp.,  extra  cloth.    7d  cents. 


14 


Henry  C.  Lea's  Publications — {Pathology). 


riROSS  [SAMUEL  D.),  M.  D., 

v^  Professor  of  Sv,rgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

ELEMENTS    OF    PATHOLOGICAL   ANATOMY.     Third    edition, 

thoroughly  revised  and  greatly  improved.     In  one  large  and  very  handsome  octavo  rolame 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
large  number  are  from  original  drawings  ;   extra  cloth.     $4  00. 
The  very  beautiful  execution  of  this  valuable  work,  and  the  exceedingly  low  price  at  which  i 
is  offered,  should  command  for  it  a  place  in  the  library  of  every  practitioner. 

To  the  student  of  medicine  we  would  say  that  we 
know  of  no  work  which  we  can  more  heartily  com- 


mend than  Gross's  Pathological  Anatomy.— /Sowt/ierw 
Med.  and  Surg.  Journal. 

The  volume  commends  itself  to  the  medical  student ; 
it  will  repay  a  careful  perusal,  and  should  be  upon 


the  book-shel  f  of  every  American  physician.— OAar/e*- 
ton  Med.  Journal.  •  > 

It  contains  much  new  matter,  and  brings  down  onr 
knowledge  of  pathology  to  the  latest  period. — London 
Lancet. 


TONES  [0.  HANd)FIELD),  F.R.S.,  and  SIEV EKING  [ED.  K),  M.D., 

*J  Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital. 

A  MANUAL  OF   PATHOLOGICAL  ANATOMY.     First  American 

edition,  revised.     With  three  hundred  and  ninetyseven  handsome  wood  engravings.     In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  760  pages,  extra  cloth,  $3  50. 


Onr  limited  space  alone  restrains  us  from  noticing 
more  at  length  the  various  subjects  treated  of  in 
this  interesting  work ;  presenting,  as  it  does,  an  excel- 
lent summary  of  the  existing  state  of  knowledge  in 
relation  to  pathological  anatomy,  we  cannot  too 
strongly  urge  upon  the  student  the  necessity  of  a  tho- 
rongh  acquaintance  with  its  contents. — Medical  Ex- 
aminer. 

We  have  long  had  need  of  a  hand-book  of  patholo- 
gical anatomy  which  should  thoroughly  reflect  the 
present  state  of  that  science.  In  the  tre.itise  before 
ns  this  desideratum  is  supplied.  Within  the  limits  of 
a  moderate  octavo,  we  have  the  outlines  of  this  great 
department  of  medical  science  accurately  defined. 


and  the  most  recent  investigations  presented  in  suffi- 
cient detail  for  the  student  of  pathology.  We  cannot 
at  this  time  undertake  a  formal  analysis  of  this  trea- 
tise, as  it  would  involve  a  separate  and  lengthy 
consideration  of  nearly  every  subject  discussed  ;  nor 
would  such  analysis  be  advantageous  to  the  medical 
reader.  The  work  is  of  such  a  character  that  every 
physician  ouglit  to  obtain  it,  both  for  reference  and 
study.-7iV.  Y.  Journal  of  Medicine. 

Its  importance  to  the  physician  cannot  be  too  highly 
estimated,  and  we  %vould  recommend  our  readers  to 
add  it  to  their  library  as  soon  as  they  conveniently 
can. — MoiUreal  Med.  Chronicle. 


GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 

Translated,  with  Notes  aud  Additions,  by  .Toseph 
Leidy,  M.  D.  In  one  volnme,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  extra  cloth.    $4  00. 


SIMON'S  GENERAL  P.\THOLOGY,  as  conducive  to 

the  Establishment  of  Kational  Principles  for  the 
Prevention  and  Cure  of  Disease.  In  one  octayo 
volume  of  212  pages,  extra  cloth.     $1  2i5. 


ITTILLIAMS  {CHARLES  J.  B.),  M.D., 

'  '  Professor  of  Clinical  Medicine  in  University  College,  London. 

PRINCIPLES  OF  MEDICINE.     An  Elementary  Yiew  of  the  Causes, 

Nature,  Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics, 
or  the  preservation  of  health.  A  new  American,  from  the  third  and  revised  London  edition. 
In  one  octavo  volume  of  about  500  pages,  extra  cloth.     $3  50. 


No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Virginia  Med.  and  Surg. 
Journal. 

There  is  no  work  in  medical  literature  which  can 
fill  the  place  of  this  one.  It  is  the  Primer  of  the 
young  practitioner,  the  Koran  of  the  scientific  one. — 
Stethoscope.     • 

A  text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Med.  Journal. 


The  absolute  necessity  of  such  a  work  must  be 
evident  to  all  who  pretend  to  more  than  mere 
empiricism.  We  must  conclude  by  again  express- 
ing our  high  sense  of  the  immense  benefit  which 
Dr.  Williams  has  conferred  on  medicine  by  the  pub- 
lication of  this  work.  We  are  certain  that  in  the 
present  state  of  our  Icnowledge  his  Principles  of  Medi- 
cine could  not  possibly  be  sui'passed. — London  Jour, 
of  Medicine. 


HARRISON'S  ESSAY  TOWARDS  A  CORRECT 
THEORY  OF  THE  NERVOUS  SYSTEM.  In  one 
octavo  volume  of  292  pp.     *1  .50. 

SOLLY  ON  THE  HUMAN  BRAIN:  its  Structure,  Phy- 
siology, and  Diseases.  From  the  Second  and  much 
enlarged  London  edition.  In  one  octavo  volume  of 
.500 pages,  with  120  wood-cuts:  exti'8   cloth.    $2  .')0. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in  its 
Historical,  Pathological,  Etiological,  and  Therapeu- 
tical Relations.  In  two  large  and  handsome  octavo 
volumes,  of  nearly  1.500  pages,  extra  cloth,  $7  00. 

LA  ROCHE  ON  PNEUMONIA  ;  its  Supposed  Connec- 
tion, Pathological,  and  Etiological,  with  Autumnal 


Fevers,  including  an  Inquiry  into  the  Existence  and 
Morbid  Agency  of  Malaria.  In  one  handsome  oc- 
tavo volnme,  extra  cloth,  of  ."iOO  paces      Price  f  S  Oft. 

BUCKLER  ON  FIBKO-BRONCHITIS  AND  RHEl^ 
MATIC  PNEUMONIA,  In  one  octavo  vol,,  extra 
clnth,  pp   1.50.     $1   2.'). 

FISKE  FUND  PRIZE  ESSAYS.— LEE  ON  THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS  DIS- 
EASE. AND  WARKEN  ON  THE  INFLUENCE  OF 
PREGNANCY  ON  THE  DEVELOPMRNT  OF  TU- 
BERCLES. Together  in  one  neat  octavo  Tolnme 
extra  cloth,    »1  00. 


B 


ARGLAY  [A.  W.),  M.  D. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;  being  an  Analysis  of  the 

Sijcns  and  Symptoms  of  Disease.     Third  American  from  the  second  and  revised  London 
edition.     In  one  neat  octavo  volume  of  451  pages,  extra  cloth.     $3  60. 


A  work  of  immense   practical    utility. — London 
Mt^iX.  Times  and  Oatette, 


The  book  should  be  in  the  hands  of  every  practical 
I  man. — DvMin  Med.  Press. 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


15 


'PLINT  [A  USTIN),  M.  D., 

■*-  Professor  of  the  Principlts  avd  Practice  of  3fedicine  in  Bellev^te  Med.  College,  N.  Y. 

A  TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Third 
edition,  reviseu  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  1002 
pages;  handsome  extra  cloth,  $6  00  j  or  strongly  bound  in  leather,  with  raised  bands,  $7  00. 
{Just  Issued.) 

From  the  Preface  to  the  Third  Edition. 
Since  the  publication,  in  December,  1866,  of  the  second  edition  of  this  treatise,  much  time  has 
been  devoted  to  its  revision.  Recognizing  in  the  favor  with  which  it  has  been  received  a  pro- 
portionate obligation  to  strive  constantly  to  increase  its  worthiness,  the  author  has  introduced  in 
the  present  edition  additions,  derived  from  his  clinical  studies,  and  from  the  latest  contributions 
in  medical  literature,  which,  it  is  believed,  will  enhance  considerably  the  practical  utility  of  the 
work.  A  slight  modification  in  the  typographical  arrangement  has  accommodated  these  additions 
without  materially  increasing  the  bulk  of  the  volume. 
New  York,  October,  1868. 

At  the  very  low  price  affixed,  the  profession  will  find  this  to  be  one  of  the  cheapest  volumes 
within  their  reach. 


This  work,  which  stands  pre-eminently  as  the  ad- 
vance standard  of  medical  science  up  to  the  present 
time  in  the  practice  of  medicine,  has  for  its  author 
one  who  is  well  and  widely  known  as  one  of  the 
leading  practitioners  of  this  continent.  In  fact,  it  is 
seldom  that  any  work  Is  ever  issued  from  the  press 
more  deserving  of  universal  recommendation. — Do- 
minion Med  Journal,  May,  1869. 

The  third  edition  of  this  most  excellent  book  scarce- 
ly needs  any  commendation  from  us.  The  volume, 
as  it  stands  now,  is  really  a  marvel :  first  of  all,  it  is 
excellently  printed  and  bound — and  we  encounter 
that  luxury  of  America,  the  ready-cut  pages,  which 
the  Yankees  are  'cute  enough  to  insist  upon — nor  are 
these  by  any  means  trifles  ;  but  the  contents  of  the 
book  are  astonishing.  Not  only  is  it  wonderful  that 
any  one  man  can  have  grasped  in  his  mind  the  whole 
scope  of  medicine  with  that  vigor  which  Dr.  Flint 
shows,  but  the  condensed  yet  clear  way  in  which 
this  is  done  is  a  perfect  literary  triumph.  Dr.  Flint 
is  pre-eminently  one  of  the  stroug  men,  whose  right 
to  do  this  kind  of  thing  is  well  admitted  ;  and  we  say 
no  more  than  the  truth  when  we  affirm  that  he  Is 
very  nearly  the  only  living  man  that  could  do  it  with 
such  results  as  the  volume  before  us. — The  London 
Practitioner,  March,  1869. 

This  is  in  some  respects  the  best  text-book  of  medi- 
cine in.  our  language,  and  it  is  highly  appreciated  on 
the  other  side  of  the  Atlantic,  inasmuch  as  the  first 
edition  was  exhausted  in  a  few  months.  The  second 
edition  was  little  more  than  a  reprint,  but  the  present 
has,  as  the  author  says,  been  thoroughly  revised. 
Much  valuable  matter  has  been  added,  and  by  mak- 
ing the  type  smaller,  the  bulk  of  the  volume  is  not 
much  increased.  The  weak  point  in  many  American 
works  is  pathology,  but  Dr.  Flint  has  taken  peculiar 
pains  on  this  point,  greatly  to  the  value  of  the  book. 
— London  Med.  Times  and  Gazette,  Feb.  6,  1869. 

Published  in  1866,  this  valuable  book  of  Dr.  Flint's 
has  in  two  years  exhausted  two  editions,  and  now 
we  gladly  announce  a  third.  We  say  we  gladly  an- 
nounce it,  because  we  are  proud  of  it  as  a  national 
representative  work  of  not  only  American,  but  of 


cosmopolitan  medicine.  In  it  the  practiceof  medicine 
is  young  and  philosophical,  based  on  reason  and  com- 
mon sense,  and  as  such,  we  hope  it  will  be  at  the 
right  hand  of  every  practitiouerof  this  vast  continent. 
— California  Medical  Gazette,  March,  1S69. 

Considering  the  large  number  of  valuable  works  in 
the  practice  of  medicine,  already  before  the  profes- 
sion, the  marked  favor  with  which  this  has  been  re- 
ceived, necessitating  a  third  edition  in  the  short  space 
of  two  years,  indicates  uuniistakahly  that  it  is  a  work 
of  more  than  ordinary  excellence,  and  must  be  accept- 
ed as  evidence  that  it  has  largely  fulfilled  the  object 
for  which  the  author  intended  it.  A  marked  feature 
in  the  work,  and  one  which  particularly  adapts  it  for 
the  use  of  students  as  a  text-book,  and  certainly  ren- 
ders it  none  the  less  valuable  to  the  busy  practitioner 
as  a  work  of  reference,  is  brevity  and  simplicity. 
The  present  edition  has  been  thoroughly  revised,  and 
much  new  matter  incorporated,  derived,  as  the  author 
informs  us,  both  from  his  own  clinical  studies,  aud 
from  the  latest  contributions  to  medical  literature, 
thus  bringing  it  fully  up  with  the  most  recent  ad- 
vances of  the  science,  and  greatly  enhancing  its  prac- 
tical utility  ;  while,  by  a  slight  modification  of  its 
typographical  arrangement,  the  additions  have  been 
accommodated  without  materially  increasing  its 
hulk. — St.  Louis  Mtd.  Archives,  Feb.  1869. 

If  there  be  among  our  readers  any  who  are  not  fa- 
miliar with  the  treatise  before  us,  we  shHll  do  them 
a  service  in  persuading  them  to  repair  their  omission 
forthwith.  Combining  to  a  rare  degree  the  highest 
scientific  attainments  with  the  most  practical  com- 
mon sense,  and  the  closest  habits  of  observation,  the 
author  has  given  us  a  vcilume  which  not  only  sets 
forth  the  results  of  the  latest  investigations  of  other 
laborers,  but  contains  more  original  views  than  any 
other  single  work  upon  this  well-woru  theme  within 
our  knowledge,— iV^.  Y.  Med.  Gazette,  Feb.  27,  1869. 

Practical  medicine  was  at  sea  when  this  book  ap- 
peared above  the  horizon  as  a  safe  and  capacious  har- 
bor. It  came  opportunely  and  was  greeted  with 
pleasurable  emotions  thronghout  the  land. — Nash' 
ville  Med.  and  Surg.  Journal,  May,  1869. 


jyUNGLISON,  FORBES,  TWEED  IE,  AND  CONOLLY. 

THE  CYCLOPEDIA  OF   PRACTICAL  MEDICINE:   comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  MeJioa  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  Ac.  &c.  In  four  large  super-royal 
octavo  volumes,  o  13254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15;  extra  cloth,  $11. 
*jif*  This  work  contaiusno  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 
by  sixty-eight  distinguished  physicians. 


The  most  complete  work  on  practical  medicine 
extant,  or  at  least  in  our  language. — Buffalo  Medical 
and  Surgical  Jotirnal. 

For  reference,  it  is  above  all  price  to  every  practi- 
'tiouer. — We.stern  Lancet. 

One  of  the  most  valuable  medical  publications  of 


the  day.     As  a  work  of  reference  it  is  invaluable.— 
Western  Journal  of  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  one  in  which 
modern  English  medicine  is  exhibited  in  the  mostad- 
vantageous  i\g)xt.— Medical  Examiner. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF  I  HOLLAND'S  MEDICAL  NOTES  AND  EEFLEC- 
MEDICINE.  With  Additions  by  D,  F,  Condib,  tioxs.  From  the  third  and  enlarged  English  edi- 
11.  D.     1  vol.  8vo.,  pp.  600,  cloth.     $2  50.  I      tion.     In   one   handsome  octavo  volume  of  about 

I     500  pages,  extra  cloth.    $3  50. 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


fTARTSHORNE  [HENR Y),  M. D., 

J- J-  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 

CINE.     A  handy-book  for  Students  and  Practitioners.     Second  edition,  revised  and  im- 
proved.    In  one  handsome  royal  ]2mo.  volume  of  450  pages,  clearly  printed  on  small  type, 
cloth,  $2  38;  half  bound,  $2  63.      {Just  Issued.) 
The  very  cordi»l  reception  with  which  this  work  has  met  shows  that  the  author  has  fully  suc- 
ceeded in  his  attempt  to  condense  within  a  convenient  compass  the  essential  points  of  scientific 
and  practical  medicine,  so  as  to  meet  the  wants  not  only  of  the  student,  but  also  of  the  praxiti- 
tioner  who  desires  to  acquaint  himself  with  the  results  of  recent  advances  in  medical  science. 

safe  and  accomplished  companion.     We  speak  thus 


As  a  strikingly  terse,  fnll,  and  comprehensive  em- 
bodiment in  a  condensed  form  of  the  essentials  in 
medical  science  and  art,  we  hazard  nothing  in  saying 
that  it  is  incomparably  in  advance  of  any  work  of  the 
kind  of  the  past,  and  will  stand  long  in  the  future 
without  a  rival.  A  mere  glance  will,  we  think,  im- 
press others  with  the  correctness  of  our  estimate.  Nor 
do  we  believe  there  will  be  found  many  who,  after 
the  most  cursory  examination,  will  fail  to  possess  it. 
How  one  could  be  able  to  crowd  so  much  that  is  valu- 
able, especially  to  the  student  and  young  practitioner, 
within  the  limits  of  so  small  a  book,  and  yet  embrace 
and  present  all  that  is  important  in  a  well-arranged, 
clear  form,  convenient,  satisfactory  for  reference,  with 
so  full  a  table  of  contents,  and  extended  general  index, 
with  nearly  three  hundred  formulas  aod  recipes,  is  a 
marvel. —  Western  Journal  of  Medicine,  Aug.  lSb7. 

The  little  book  before  us  has  this  quality,  and  we 
can  therefore  say  that  all  students  will  find  it  an  in- 
valuable guide  in  their  pursuit  of  clinical  medicine. 
Dr.  Hartshorne  speaksof  itas  "an  unambitious  effort 
to  make  useful  the  experience  of  twenty  years  of  pri- 
vate and  hospital  medical  practice,  with  its  attendant 
study  and  reflection."  That  the  effort  will  prove  suc- 
cessful we  have  no  doubt,  and  in  his  study,  and  at 
the  bedside,  the  student  will  find  Dr.  Hartshorne  a 


highly  of  the  volume,  because  it  approaches  more 
nearly  than  aoy  similar  manual  lately  before  us  the 
standard  at  which  all  such  books  should  aim  —  of 
teaching  much,  and  suggesting  more.  To  the  student 
we  can  heartily  recommend  the  work  of  our  transat- 
lantic colleague,  and  the  btisy  praciitioner,  we  are 
sure,  will  find  in  it  the  means  of  solving  many  a 
doubt,  and  will  rise  from  the  perusal  of  its  pages, 
having  gained  clearer  views  to  guide  him  in  his  daily 
struggle  with  disease. — Dub.  Med.  Press,  Oct.  2,  1867. 
This  work  of  Dr.  Hartshorne  must  not  be  confound- 
ed with  the  medical  manuals  so  generally  to  be  found 
in  the  hands  of  students,  serving  them  at  best  but  as 
blind  guides,  better  adapted  to  lead  them  astray  than 
to  any  useful  and  reliable  knowledge.  The  work  be- 
fore us  presents  a  careful  synopsis  of  the  essential 
elements  of  the  theory  of  diseased  action,  its  causes, 
phenomena  and  results,  and  of  the  art  of  healing,  as 
recognized  by  the  most  authoritative  of  our  profes- 
sional writers  and  teachers.  A  very  careful  and  can- 
did examination  of  the  volume  has  convinced  us  that 
it  will  be  generally  recognized  as  one  of  the  best  man- 
uals for  the  use  of  the  student  that  has  yet  appeared. 
— American  Journal  Med.  Sciences,  Oct.  1867. 


TU:a  TSON  [THOMAS),  M.  D.,  ^c. 

LECTURES     ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.     Delivered  at  King's  College,  London.     A  new  American,  from  the  last  revised 
and  enlarged  English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of 
"  A  Practical  Treatise  on  the  Diseases  of  Children,"  &o.     With  one  hundred  and  eighty- 
five  illustrations  on  wood.     In  one  very  large  and  handsome  volume,  imperial  octavo,  of 
over   1200  closely  printed  pages  in  small  type ;    extra  cloth,  $6  60 ;  strongly  bound   in 
leather,  with  raised  bands,  $7  60. 
Believing  this  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and  be  in  the  hands 
of  every  student,  every  effort  has  been  made  to  condense  the  vast  amount  of  matter  which  it  con- 
tains within  a  convenient  compass,  and  at  a  very  reasonable  price,  to  place  it  within  reach  of  all. 
In  its  present  enlarged  form,  the  work  contains  the  matter  of  at  least  three  ordinary  octavos, 
rendering  it  one  of  the  cheapest  works  now  offered  to  the  American  profession,  while  its  mechani- 
cal execution  makes  it  an  exceedingly  attractive  volume. 


DICKSON'S  ELEMENTS  OF  MEDICINE;  a  Compen- 
dious View  of  Pathology  and  Therapeutics,  or  the 
History  and  Treatment  of  Diseases.  Second  edi- 
tion, revised.  1  vol.  8vo.  of  750  pages,  extra  cloth. 
$4  00. 

WHAT  TO  OBSERVE  ATTHE  BEDSIDE  AND  AFTER 
Death  in  Medical  Cases.  Published  under  the 
authority  of  the  London  Society  for  Medical  Obser- 


vation.   From  the  second  London  edition.    1  vol. 
royal  12mo.,  extra  cloth.    $1  00. 

LAYCOCK'S  LECTURES  ON  THE  PRINCIPLES 
AND  Methods  of  Medical  Observation  and  Rb- 
8EABCH.  For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12iao. 
volume,  extra  cloth.    $1  00. 


TpULLER  [HENRY  WILLIAM),  M.  D., 

-*•  Physician  to  St.  George's  Hospital,  London. 

ON  DISEASES  OF  THE   LUNGS   AND   AIR-PASSAGES.     Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.  From  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $3  50. 
{Just  Issued.) 

accordingly  we  have  what  might  be  with  perfect  jus- 
tice styled  an  entirely  new  work  from  his  pen,  the 
portion  of  the  work  treating  of  the  heart  and  great 
vessels  being  excluded.  Nevertheless,  this  volume  is 
of  almost  equal  size  with  the  first. — London  MediccU 
Times  and  Gazette,  July  20,  1867. 


Dr.  Fuller's  work  on  diseases  of  the  chest  was  so 
favorably  received,  that  to  many  who  did  not  know 
the  extent  of  his  engagements,  it  was  a  matter  of  won- 
der that  it  should  be  allowed  to  remain  three  years 
out  of  print.  Determined,  however,  to  improve  it. 
Dr.  Fuller  would  not  consent  to  a  mere  reprint,  and 


jDRINTON  [WILLIAM),  M.D.,  F.R.S. 
-^LECTURES  ON  THE  DISEASES  OF  THE  STOMACH;  with  an 

Introduction  on  its  Anatomy  and  Physiology.     From  the  second  and  enlarged  London  edi- 
tion.    With  illustrations  on  wood.     In  one  handsome  octavo  volume  of  about  300  pages, 
extra  cloth.     $3  2b. {Just  issued.) 
Nowhere  can  be  found  a  more  full,  accurate,  plain,  I      The  most  complete  work  In  our  lasguage  upon  the 
and  instructive  history  of  these  diseases,  or  more  ra-  |  diagnosis  and  treatment  of  these  puz/liug  and  impor- 
ti'.Qal  views  respecting  their  pathology  and  therapeu-  I  tant  diseases. — Boston  Med.  and  Surg.  Joli.rna^,'S^<yv, 
tics. — Am.  Joum.  of  the  Med.  Sciences,  April,  1865.     |  1865. 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


n 


JOILINT  [A  USTIN),  M.  D., 

-*■  Prdfes.ior  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hotpital  Med.  College,  N.  T. 

A  PRACTICAL  TREATISE  OX  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  piiges,  with  a  plate,  extra  cloth,  $4.     {Nuw  Ready.) 

The  author  has  sedulously  improved  the  opportunity  afiForded  him  of  revising  this  work.   Portions 

of  it  have  been  rewritten,  and  the  whole  brought  up  to  a  level  with  the  most  advanced  condition  of 

science.  It  must  therefore  continue  to  maintain  its  position  as  the  staridard  treatise  on  the  subject. 

Dr.  Flint  chose  a  dilBcuU  subject  for  bis  researches,  |  able  for  purposes  of  illustration,  in  counection  with 


and  has  shown  remarkable  powers  of  observation 
And  reflection,  as  well  as  great  industry,  in  his  treat- 
ment of  it.  His  book  must  be  considered  the  fullest 
ajid  clearest  practical  treatise  on  those  subjects,  and 
should  be  in  the  hands  of  all  practitioners  and  stu- 
dents. It  is  a  credit  to  American  medical  literature. 
— Amer.  Journ.  of  the  Med.  Sciences,  July,  1S60. 

We  question  the  fact  of  any  recent  American  author 
in  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  williugly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart, 
in  making  an  extended  personal  clinical  study  avail- 


cases  which  have  been  reported  by  other  tru.stworthy 
observers. — Brit,  and  For.  Med.-Chirurg.  Revieto. 

In  regard  to  the  merits  of  the  work,  we  have  no 
hesitation  in  pronouncing  it  full,  accurate,  and  judi- 
cious. Considering  the  present  slate  of  science,  soch 
a  work  was  mnch  needed.  It  should  be  in  thehanda 
of  every  practitioner. — Chicago  Med.  Journ. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  .wide  gap  on  the  list  of  text- 
books for  our  schools,  and  is,  for  the  practitioner,  the 
most  valuable  practical  work  of  its  kind. — .y.  0.  Med. 
News. 


^T  THE  SAME  AUTHOR.    (Just  Issued.) 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OP  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octuvo  volume 
of  595  pages,  extra  cloth,  $4  50. 

American  medicine. — Atlanta  Med.  and  Surg.  Jour- 
nal, Feb.  1S67. 

The  chapter  on  Phthisis  Is  replete  with  interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint's  style  is  clear  and 
elegant,  and  the  toue  of  freshness  and  originalitjT 
which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  19,  1867. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  the 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a  little  original  observation. — 
Banking's  Abstract,  Jau.  1867. 


Premising  this  observation  of  the  necessity  of  each 
student  and  practitioner  making  himself  acquainted 
with  auscultation  and  percussion,  we  may  state  our 
honest  opinion  that  Dr.  Flint's  treatise  is  one  of  the 
most  trustworthy  guides  which  he  can  consult.  The 
style  is  clear  and  distinct,  and  is  also  concise,  being 
free  from  that  tendency  to  over-re finemeut  and  unne- 
oessary  minuteness  which  characterizes  many  works 
on  the  same  subject. — Dublin  Medical  Press,  Feb.  6, 
1S67. 

In  the  invaluable  work  before  us,  we  have  a  book 
of  facts  of  nearly  600  pages,  admirably  arranged, 
«lear,  thorough,  and  lucid  ou  all  points,  without  pro- 
lixity; exhausting  every  point  and  topic  touched  ;  a 
monument  of  patient  and  long-continued  observation, 
which  does  credit  to  its  author,  and  reflects  honor  on 


F 


AVF{F.  W.),  M.D.,F.R.S. 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Cfuy's  Hospital,  &c. 

A  TREATISE  ON  THE    FUXCTIOX  OF  DIGESTIOX ;  its  Disor- 
ders and  their  Treatment.     From  the  second  London  edition.     In  one  handsome  volume, 
small  octavo,  extra  cloth,  $2  00.     {Just  Ready.) 
The  work  before  us  is  one  which  deserves  a  wide     treatise,  and  sufflciently  exhaustive  for  all  practical 
circulation.    We  know  of  no  better  guide  to  the  study     purposes. — Leavenworth  Med.  Herald,  July,  1869. 
of  digestion  and  its  disorders.— St.  Louis  Med.  and        ^  ^g^y  yaluable  work  on  the  subject  of  which  it 
Surg.  Journal,  July  10,  1869.  treats.    Small,  yet  it  is  full  of  valuable  informatiou. 

A  thoroughly  good  book,  being  a  careful  systematic     — Cincinnati  Mtd.  Repertory,  June,  1869. 


(IHAMBERS  [T.  K.),  M.B., 

'-^  Consulting  Physician  to  St.  Mary's  Hospital,  London,  <6c. 

THE  INDIGESTIONS ;  or,  Diseases  of  the  Digestive  Organs  Functionally 

Treated.    Third  and  revised  Edition.    In  one  handsome  octavo  volume  of  383  pages,  extra 
cloth.     $3  00.     {Now  Ready.) 

Author's  Preface. 

Sitrce  publishing  my  first  edition,  I  have  inserted  upwards  of  ten  dozen  causes,  and  have  rear- 
ranged, indeed  in  part  rewritten,  the  commentary  upon  them.  ■  A  third  edition  is  not  yet  required 
in  England,  so  I  send  the  MS.  for  publication  to  America.  I  have  faith  in  the  kindly  feeling 
with  which  it  will  be  received  there. 

London,  December,  1869. 

We  look  upon  this  chapter  as  a  most  valuable  guide 
to  physicians,  and  warning  to  patients  concerning 
transgressions  against  the  established  physiological 
conduct  of  life.  The  advice  as  to  medical  treatment 
proper,  is  also  most  serviceable.  It  should  be  read 
by  every  medical  man  in  the  country,  and  he  should 
read  his  lessons  to  his  patients  from  out  its  pages.    We 


only  regret  that  we  have  no  room  for  a  more  thorough 
analysis  of  its  contents.— A^  Y.  Medical  Journal, 
March,  1868. 

The  work  should  be  ia  the  hands  of  every  practis- 
ing physician. — Boston  Med.  and  Surg.  Journal, 
Nov.  21,  1867. 


HABEBSHON  ON  DISEASES  OF  THE  ALIMENTARY 
CANAL,  (ESOPHAGUS,  STOMACH,  C^CUM,  AND 
INTESTINES.  With  illustrations  on  wood.  One 
vol.  8vo.,  312  pages,  extra  cloth.    $2  50. 

CLYMEE  ON  FEVERS;    THEIR  DIAGNOSIS   PA- 


THOLOOT  AND  TREATMENT.      lu  One    OCtaVO  VOlUDle 

of  fiOO  pages,  leather.    ^^  TH. 
TODD'SCHNICAL  LECTURES  ON  CERTAIN  ACUTB 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
extra  cloth.    $2  00. 


18 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


f?0 BERTS  (  WILLIAM),  M.  D., 

-*■*'  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  Ac. 

A  PRACTICAL  TREATISE    ON  URINARY  AND   RENAL   DIS- 

EASES,  including  Urinary  Deposits.    Illustrated  by  numerous  eases  and  engravings.    Sec- 
ond Edition,  Revised.     In  one  very  handsome  octavo  volume.     {Prej)ari7ig.) 


-DASHAM  (  TT^.  R.),  M.  D., 

J-^  Senior  Physician  to  the  Westminster  Hospital,  &c. 

RENAL  DISEASES:  a  Clinical  Guide  to  their  Diagnosis  and  Treat- 
ment. With  illustrations.  In  one  neat  royal  12mo.  volume  of  304  pages.  $2  00.  {Just 
Issiied. ) 

It  is  with  the  view  of  promoting  a  practical  and  clinical  knowledge  of  a  class  of  diseases  which 
are  not  without  their  difficulties  in  diagnosis  that  the  present  work  has  been  prepared,  with  the 
hope  that  both  student  and  young  practitioner  may  by  it  be  assisted  in  their  clinical  observations. 

— Author''s  Preface. 

The  chapters  on  diagnosis  and  treatment  are  very  I  ment  render  the  book  pleasing  and  convenient. — Am. 
good,  and  the  student  and  young  practitioner  will    Jnurn.  Med.  Sciences,  July,  1870. 
find  them  full  of  valuable  practical  hints.     The  third        ^  book  that  we  believe  will  be  found  a  valuable 


part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  novel,  and,  we  think,  u.se- 
ful  form.  Here  everything  can  he  easily  fouud,  ami, 
what  is  more  important,  easily  read,  for  all  the  dry 
details  of  larger  books  here  acquire  a  new  interest 
from  the  author's  arrangement.  This  part  of  the 
book  is  full  of  good  work. — Brit,  and  For.  Medico- 
Chirurgical  Review,  July,  1870. 

The  easy  descriptions  and  compact  modes  of  state- 


asKistant  to  the  practitioner  and  guide  to  the  student. 
— Baltimore  Med.  Journal,  July,  1370. 

The  treatise  of  Dr.  Basham  differs  from  the  rest  in 
its  special  adaptation  to  clinical  study,  and  its  con- 
densed and  almost  aphorismal  style,  which  makes  it 
easily  read  and  easily  uuderstood  Besides,  the 
author  expresses  some  new  viwws,  which  are  well 
worthy  of  consideration.  The  volume  is  a  vaUiahle 
addition  to  this  department  of  knowledge. — Pacific 
Med.  and  Surg.  Journal,  July,  1870. 


MORLAND  ON  RETENTION  IN  THE  BLOOD  OF  THE  ELEMENTS  OF  THE  URINARY    SECRETION. 
1  vol.  Svc,  extra  cloth.    75  cents. 


TONES  [G.  HANDFIELD),  M.  D., 

^  Physician  to  St.  Mary's  Hospital,  &c. 

CLINICAL    OBSERYATIONS 

DISORDERS.     Second  American  Edition, 
extra  cloth,  $.3  25.     (Jkst  Isstied.) 

Taken  as  a  whole,  the  work  before  us  furnishes  a 
short  but  reliable  account  of  the  pathology  and  treat- 
ment of  a  class  of  very  common  but  certainly  highly 
obscure  disorders.  The  advanced  student  will  tind  it 
a  rich  mine  of  valuable  facts,  while  the  medical  prac- 
titioner will  derive  from  it  many  a  suggestive  hiut  to 
aid  him  in  the  diagnosis  of  "nervous  cases,"  and  in 
determining  the  true  indications  for  their  ameliora- 
tiou  or  cure. — Amer.  Journ.  Med.  Set.,  Jan.  1867. 


ON   rrNCTIONAL   NERVOUS 

In  one  handsome  octavo  volume  of  348  pages, 

We  must  cordially  recommend  it  to  the  professton 
of  this  country  as  supplying,  in  a  great  measure,  a 
deficiency  which  exists  in  the  medical'  literature  of 
the  English  language. — Kew  York  Med.  Journ.,  April, 
1867. 

The  volume  is  a  most  admirable  one — full  of  hfnts 
and  practical  suggestions.  —  Canada  Med.  Journal, 
April,  1867. 


s 


.D. 


LADE  [D.  D.), 

DIPHTHERIA ;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  neat 
royal  12m{).  volume,  extra  cloth.     $125.     (Just  issued.) 


SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MEDIABLE STAGES.  In  one  neat  octavo  volume 
of  2.1-t  pages,  extra  cloth.    $2  2.5. 

SALTER  ON  ASTHMA  ;  its  Pathology,  Causes,  Con- 
sequences, and  Treatmeut.  In  one  volume  octavo, 
extra  cloth.    $2  50. 


WALSHE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  THE  HEART  AND  GREAT  VESSELS. 
Third  American,  from  the  third  revised  and  much 
enlarged  London  edition.  In  one  handsomeoctavo 
volume  of  420  pages,  extra  cloth.    $3  00. 


jrUDSON  [A.],  M.  D.,  M.  R.  I  A., 

•*■-*-        Physician  to  the  Meath  Hospital. 

LECTURES  ON  THE  STUDY 

Cloth,  $2  50.     {Jtist  Issued.) 

As  an  admirable  summary  of  the  present  state  of 
our  knowledge  concerning  fever,  the  work  will  be  as 
welcome  to  the  medical  man  in  active  practice  as  to 
the  student.     To  the  hard-worked  practitioner  who 
wishes  to  refresh  his  notions  concerning  fever,  the 
book  will  prove  most  valuable.  ......  We  heartily 

commend  his  excellent  volume  to  students  and  the 
professiou  at  large. — London  Lancet,  .lune  22,  1867. 

The  truly  philosophical  lectures  of  Dr.  Hudson  add 


OF  FEVER.     In  one  vol.  8vo.,  extra 


much  to  our  previous  knowledge,  all  of  which  they, 
moreover,  analyze  and  condense.  This  well-conceived 
task  has  been  admirably  executed  iu  the  lectures,  il- 
lustrative cases  and  quotations  being  arranged  in  an 
appendix  to  each.  We  regret  that  space  forbids  our 
quotation  from  the  lectures  on  treatment,  which  are, 
in  regard  to  research  and  judgment,  most  masterly, 
and  evidently  the  result  of  extended  and  mature  ex- 
perience.— British  Medical  journal,  Feb.  23, 1868. 


TYONS  [ROBERT  D.),  K.  C.  C. 


A  TREATISE  ON  FEVER;  or,  Selections  from  a  Course  of  Lectures 

on  Fever.    Being  part  of  a  Course  of  Theory  and  Practice  of  Medicine.   In  one  neat  octavo 
volume,  of  362  pages,  extra  cloth.     $2  25. 


Henry  C.  Lea's  Publications — (Venereal  Diseases,  etc.).  19 


-nUMSTE AD  [FREEMAN  J.),  M.D.. 

J-J         P'l-iipsi'or  rtf  Venereal  Diseases  at  the  Col.  «f  Phyi  "nd  Unrg.,  Sew  YorM.  A-c. 

THE   PATHOLOGY  AND   TREATMENT   OF   VENEREAL  DIS- 

EASES.     Including  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 
revised  and  enlarged,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  extra  cloth.     (^Nearly  Heady.) 
WfiU  knowa  as  one  of  the  be.'it  authorities  of  the    every  other  treatise  on  Venereal.— San  Francwco 


present  day  on  the  siibject. — British  and  For.  Med.- 
OMrrirg.  Review,  April,  1866. 

A  regular  store-house  of  special  information. — 
London  Lancet,  Feb.  2-1,  1866. 

A  remarkably  clear  and  fnll  systemtitic  treatise  on 
the  whole  subject. — Land.  Med.  Times  and  Gazette.. 

The  best,  complelest,  fullest  monograph  on  this 
subject  in  our  language. — British  American  Journal. 

Indispensahle  in  a  medical  library. — Pacific  Med. 
and  Surg.  Journal. 
We  have  no  doubt  that  it  will  supersede  in  America 


Afed.  Press,  Oct.  1S64. 

A  perfect  compilation  of  all  that  is  worth  knowing 
on  vpnereal  diseases  in  general.  It  fills  up  a  gap 
which  has  long  been  felt  in  English  medical  literature. 
— Brit,  and  Foreign  Med.-Chirurg.  Review,  Jan.,  '6.5. 

We  have  not  met  with  any  which  so  highly  merits 
our  approval  and  praise  as  the  second  edition  of  Dr. 
Bumstead's  work. — Glasgow Mtd.  Journal,  Oct.  1864. 

We  know  of  no  treatise  in  any  language  which  ia 
its  equal  in  point  of  completeness  and  practical  sim- 
plicity.—Boston  Medical  and  Surgical  Journal, 
Jan.  30,  1S64. 


(lULLERIER  [A.),  and 

^  Surgeon  to  the  Udpital  du  Midi. 


TDDMSTEAD  [FREEMAN  J.), 

•*-■'       Profejisor  of  Venereal  Disrases  in  the  Collegeof 
Physicians  and  Surgeons,  N.  7. 

AN    ATLAS    OF    VENEREAL   DISEASES.      Translated    and    Edited    by 
Freeman  J.  Bumstead.     In  one  large  imperial  4to.  volume  of  .328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  extra  cloth,  $17  00 ;  also,  in  five  parts,  stout  wrappers  for  mailing,  at 
$3  per  part.     {Just  Ready.) 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  verj'  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  thi.«  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  we'l  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


We  wish  for  once  that  our  province  was  not  restrict- 
ed to  methods  of  irpatment,  that  we  might  say  some- 
thing of  the  exiiuisite  colored  plates  in  this  volume. 
— London  Practitioner,  May,  1869. 

As  a  whole,  it  teaches  all  that  can  he  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  1869. 

Superior  to  anything  of  the  kind  ever  before  issued 
oil  this  continent. — Canada  Med.  Journal,  March,  '69. 

The  practitioner  who  desires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  pubiished. — 
Dominion  Med.  Journal,  May,  1869. 

This  is  a  work  of  master  hands  on  both  sides.  M. 
Cullerier  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  of  the  illustrious  and  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival 
Assuring  our  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 
to  its  end,  we  do  not  know  a  single  medical  work, 
which  for  its  kind  is  more  necessary  for  them  to  have. 
— California  Med.  Gazette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
Fiench  original. — Am.  Journ.  Med.  Sciences,  Jan. '69 


The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illustrations  surpass  those  of  previous 
aumhevs.— Boston  Med.  and  Surg.  Journal,  Jan.  14, 
1869. 

Other  writers  besides  M.  Cullerier  have  given  us  a 

good  account  of  the  disea.ses  of  which  he  treats,  but 
no  oue  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases.  There  i«, 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  for  it  is  an  American  reprint 
and  translation  of  M.  Cullorier's  work,  with  inci- 
dental remarks  by  one  of  the  most  eminent  American 
syphilographers,  Mr.  Bumstead.  The  letter-press  is 
chiefly  M.  Cullerier's,  but  every  here  and  there  a  few 
lines  or  sentences  are  introduced  by  Mr.  Bumstead  ; 
aud,  as  M.  Cullerier  is  a  unicist,  while  Mr.  Bumstead 
is  a  dualist,  this  method  of  treating  the  subject  adds 
very  much  to  its  interest.  By  this  means  a  liveliness 
is  imparted  to  the  volume  which  many  other  treatises 
sorely  lack.  It  is  like  reading  the  report  of  a  conver- 
sation or  debate;  for  Mr.  Bumstead  often  finds  occa- 
sion to  question  M. Cullerier's  statements  or  inferences, 
and  this  he  does  in  a  short  and  forcible  way  which 
helps  to  keep  up  the  attention,  and  to  make  the  book 
a  very  readable  one. — Brit,  and  For.  Medico-Chir. 
Rerie^o,  July,  1869. 


fTILL  [BERKELEY), 

-*-*  Surgeon  to  the  Lock  Hospital,  London. 


In 


ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

one  handsome  octavo  volume  ;  extra  cloth,  $3  25.     iJ7ist  Issued.) 

The  author,  from  a  vast  amount  of  material,  with 
all  of  which  he  was  perfectly  familiar,  has  under- 
taken to  construct  a  new  book,  and  has  really  sucr 
ceeded  in  producing  a  capital  volume  upon  this 
subject. — Nashville  Med.  and  Surg.  Journal,  May, 
1869. 


Bilnging,  as  it  does,  the  entire  literature  of  the  dis- 
ease down  to  the  present  day,  aud  giving  with  great 
ability  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
find  a  place  in  the  library  of  every  surgeon. — Cali- 
fornia Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  careful 
attention  to  the  manifold  aspects  and  details  of  its 
subject,  it  is  womierfully  concise.  All  these  qualities 
render  it  an  especially  valuable  book  to  the  beginner, 
to  whom  we  would  most  earnestly  recommend  its 
study ;  while  it  is  no  less  useful  to  the  practitioner. — 
St.  Louis  Med.  and  Surg.  Journal,  May,  1869. 


The  most  convenient  and  ready  book  of  reference 
we  have  met  with.— A'.  Y.  Med.  Record,  May  1,  1869. 

Most  admirably  arranged  for  both  student  and  prac- 
titioner, DO  other  work  on  the  subject  equals  it ;  it  is 
more  simple,  more  easily  studied. — Buffalo  Med.  and 
Surg.  Journal,  March,  1869. 


ALLEMAND  AND   WILSON. 
'a   practical  treatise    on    the    CAUSES,    SYMPTOMS, 

AND   TREATMENT   OP   SPERMATORRHCEA.     By  M.  Lallemand.     Fifth  American 

edition.     To  which  is  added ON  DISEASES  OF  THE  VESICULiE  SEMINALES. 

By  Maeris  Wilson,  M.D.    In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth,  $2  74. 


20 


Henry  C.  Lea's  Publications — {Diseases  of  the  Skin). 


TVILSON  ( ERASM  US ) ,  F.  R.  S. 

ON  DISEASES  OF  THE  SKIN.     With  Illustrations  on  wood.    Sev- 

etith  American,  from  the  sixth  and  enlarged  English  edition.     In  one  large  octavo  volume 
of  over  800  pages,  $5.     (Just  Issued.) 

A  SERIES  OF  PLATES  ILLUSTRATING  "WILSON  ON  DIS- 
EASES OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen afe  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.  Price,  in  extra  cloth,  $5  50. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Extra  cloth,  $10. 

From  the  Preface  to  the  Sixth  English  Edition. 
The  present  edition  has  been  carefully  revised,  in  many  parts  rewritten,  and  our  attention  has 
been  specially  directed  to  the  practical  application  and  improvements  of  treatment.  And,  in 
conclusion,  we  venture  to  remark  that  if  an  acute  and  friendly  critic  should  discover  any  differ- 
ence between  our  present  opinions  and  those  announced  in  former  editions,  we  have  only  to  ob- 
serve that  science  and  knowledge  are  progressive,  and  that  we  have  done  our  best  to  move  onward 
with  the  times. 

The  industry  and  care  with  which  the  author  has  revised  the  present  edition  are  shown  by  the 
fact  that  the  volume  has  been  enlarged  by  more  than  a  hundred  pages.  In  its  present  improved 
form  it  will  therefore  doubtl*ss  retain  the  position  which  it  has  acquired  as  a  standard  and  classical 
authority,  while  at  the  same  time  it  has  addition<al  claims  on  the  attention  of  the  profession  as 
the  latest  and  most  complete  work  on  the  subject  in  the  English  language. 


Such  a  work  as  the  one  before  ns  is  a  most  capital 
and  acceptable  help.  Mr.  Wilson  has  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re- 
garded as  one  of  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
and  brought  up  in  its  revision  to  the  present  time.  In 
this  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  fidelity  the  various  groups  of 
diseases  treated  of  in  the  body  of  the  work. — Cin- 
cinnati Lancet,  June,  1S63. 

No  one  treating  skin  diseases  should  be  without 
a  copy  of  this  standard  work. —  Canada  Lancet. 
August,  1863. 


We  can  safely  recommend  it  to  the  profession  as 
the  best  work  on  the  subject  now  in  existence  in 
the  English  language. — Medical  Times  and  Gazette. 

Mr.  Wilson's  volume  is  an  excellent  digest  of  tb« 
actual  amount  of  knowledge  of  cutaneous  diseasea; 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  the 
skin. — British  and  Foreign  Medical  Review. 

These  plates  are  very  accurate,  and  are  executed 
with  an  elegance  and  taste  which  are  highly  creditable 
to  the  artistic  skill  of  the  American  artist  whoexecuted 
them. — St.  Louis  Med.  Journal. 

The  drawings  are  very  perfect,  and  the  finish  and 
coloring  artistic  and  correct;  the  volume  is  an  indis- 
pensable companion  to  the  book  it  illustrates  and 
completes. — Charleston  Medical  Journal. 


THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

BASES  OF  THE  SKIN.    In  One  Very  handsome  royul  12mo.  volume.   $3  60.    (Lately  Issued.) 

fJELIGAN  {J.  MOORE),  M.D.,  M.R.I.A. 

A    PRACTICAL    TREATISE    ON    DISEASES    OF   THE    SKIN 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.  D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.     $2  25.     (Just  Issued.) 

Fully  equal  to  all  the  requirements  of  students  and  fully  up  to  the  times,  and  is  thoroughly  stocked  with 
young  practitioners.  It  is  a  work  that  h,as  stood  its 
ground,  that  was  worthy  the  reputation  of  the  au- 
thor, and  the  high  position  of  wliich  has  been  main- 
tained by  its  learned  editor. — Dvhlin  Med.  Pressand 
Circular,  Nov.  17,  1869. 

Of  the  remainder  of  the  work  we  have  nothing  be- 
yond unqualified  commendation  to  offer.  It  is  so  far 
the  most  complete  one  of  its  size  that  has  appeared, 
and  for  the  student  there  can  be  none  which  can  com- 
pare with  it  in  practical  value.  All  the  late  disco- 
veries in  Dermatology  have  been  duly  noticed,  and  ]  by  the  student. — Chicago  Med.  Journal,  Dec.  1866. 
their  value  justly  estimated ;  in  a  word,  the  work  is 

?r  THE  SAME  AUTHOR.  — 


most  valuable  information. — New  York  Med.  Record, 
Jan.  15,  1867. 

This  instructive  little  volume  appears  once  more. 
Since  the  death  of  its  distinguished  author,  the  study 
of  skin  diseases  has  been  considerably  advanced,  and 
the  results  of  these  investigations  have  been  added 
by  the  present  editor  to  the  original  work  of  Dr.  Neli- 
gan.  This,  however,  has  not  so  far  increased  its  bulk 
as  to  destroy  its  reputation  as  the  most  convenient 
manual  of  diseases  of  the  skin  that  can  be  procuwd 


B' 


ATLAS   OF   CUTANEOUS   DISEASES.     In  one  beautiful  quarto 

volume,  with  exquisitely  colored  plates,  Ac,  presenting  about  one  hundred  varieties  of 
disease.     Extra  cloth,  $5  50. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  diflflcult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  "Atlas"  we  have  been  indaced  to 
examine  also  the  "Practical  Treatise,"  and  we  are 


inclined  to  consider  It  a  very  superior  work,  com- 
bining accurate  verbal  description  with  sound  views 
of  the  pathology  and  treatment  of  eruptive  diseases. 
—  Glasgow  Med.  Journal. 

A  compend  which  will  very  mncli  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valuable  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


TJILLIER  {THOMAS),  M.D., 

•*-*  Physician  to  the  Skin  Department  of  University  College  Hospital,  Ac. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.     In  one  royal  12mo.  volume  of  358  pp.     With  Illustrations. 
Extra  cloth,  $2  25.     (Nou>  Ready.) 


Henry  C.  Lea's  Publications — (Diseases  of  Children). 


21 


(^MITH  {J.  LE  WIS),  M.  D., 

^^  Pro/esxnr  of  Morbid  Anatomy  in  the  Bellevue  HoxpUal  Med.  CnUege,  iV   T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    In  one  handsome  joctaTO  volume  of  620  pages,  extra  cloth,  $4  75  ;  leather, 
$5  76.      (Just  Issiud.) 
We  have  no  work  upon  the  Diseases  of  Infancy  and  |  of  the  diseases  of  childhood,  eminently  fli  him  for  the 


Childhood  which  can  compare  with  it. — Buffalo  Med 
and  Surg.  Journal,  March,  1S69. 

The  description  of  the  pathology,  symptoms,  and 
treatment  of  the  different  diseases  is  excellent. — Am. 
Med.  Journal,  April,  1869. 

So  full,  satisfactory,  and  complete  is  the  information 
to  be  derived  from  this  work,  that  at  no  time  have  we 
examined  the  pages  of  any  book  with  more  pleasure. 
The  diseases  incident  to  childhood  are  treated  with  a 
clearness,  precision,  and  understanding  that  is  not 
often  met  with,  and  which  must  call  forth  the  ap- 
proval of  all  who  consult  its  pages. — Cincinnati  Med. 
Rejjertory,  May,  1869. 

The  author  of  this  volume  is  well  known  as  a 
valued  contributor  to  the  literature  of  his  specialty. 
The  faithful  manner  in  which  he  has  worked  in  the 
public  institutions  with  which  he  has  been  connected, 
the  conscientioas  regard  for  truth  which  has  for  years 
characterized  all  his  researches,  the  great  amount  of 
experience  which  he  has  been  enabled  to  acquire  in 


task  which  he  has  taken  upon  himself  The  remark- 
able faculty  of  bringing  out  salient  points  and  stating 
concisely  other  less  imporiant  fact.s,  euables  him  to 
crowd  within  a  small  compass  a  vast  amount  of  pracv 
tical  information.  The  attention  given  to  the  treat- 
ment of  the  varioac  maladies,  as  well  as  the  presenta- 
tion of  all  the  recently  accepted  pathological  views, 
make  it  one  of  the  most  valuable  treatises,  within  it?i 
present  compass,  that  can  be  placed  in  the  hands  of 
any  seeker  after  truth.  The  volume  as  a  whole  will 
still  further  establish  for  the  writer  a  permanent  and 
enviable  reputation  as  a  careful  observer,  an  impar- 
tial interpreter,  a  safe  and  trustworthy  adviser,  and 
a  modest  and  untiring  student. — N.  T.  Med.  Record, 
March  1.5,  1869. 

We  have  perused  Dr.  Smith's  book  with  not  a  little 
satisfaction;  it  is  indeed  an  excellent  work  ;  well  and 
correctly  written ;  thoroughly  up  to  the  modern  ideas ; 
concise,  yet  complete  in  its  material.  We  cannot  help 
welcoming  a  work  which  will  be  worthy  of  reliance 
1  as  a  text-book  for  medical  students  and  younger  phy- 


the  treatment  of  infantile  diseases,  and  the  care  which  '  (;icians  in  their  investigation  of  disease  i'n  thildcen. 
he  has  accustomed  himself  to  take  in  the  stndy.of  the  ■  Boston  Med.  and  Surg.  Journal,  March  i,  lad9. 
significant  facts  relating  to  the  pathological  anatomy  | 

ffONDIE  [D.  FRANCIS),  M.D. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  extra  cloth,  $5  25  ;  leather,  $6  25.       (Lately  Issued.) 

before  his  countrymen  as  one  peculiarly  pre-eminent 
in  this  department  of  medicine  His  work  lias  been 
so  long  a  standard  for  practitioners  and  medical  stu- 
dents that  we  do  no  more  now  than  refer  to  the  fact 
that  it  has  reached  its  sixth  edition.  We  are  glad 
once  more  to  refresh  the  impressions  of  our  earlier 
days  by  wandering  through  its  pages,  and  at  the  same 
time  to  be  able  to  recommend  it  to  the  youngest  mem- 
bers of  the  profession,  as  well  as  to  those  who  have 
the  older  editions  on  their  shelves. — St.  Louis  Mtd. 
Reporter,  Feb.  15.  186S. 

We  pronounced  the  first  edition  to  be  the  best  work 
on  the  diseases  of  children  in  the  English  language, 
and,  notwithstanding  all  that  has  been  published,  we 
still  regaid  it  in  that  light.— Jtredicai  ExamiTier. 


Dr.  Condie  has  been  one  of  those  who  have  per- 
formed such  a  service  satisfactorily,  and,  as  a  result, 
his  popular,  comprehensive,  and  practical  work  has 
received  that  high  compliment  of  approval  on  the 
part  of  his  brethren,  which  several  editions  incontes- 
tably  set  forth.  The  present  edition,  which  is  the 
sixth,  is  fully  up  to  the  times  in  the  discussion  of  all 
those  points  in  the  pathology  and  treatment  of  infan- 
tile diseases  which  have  been  brought  forward  by  the 
German  and  French  teachers.  As  a  whole,  however, 
the  work  is  the  best  American  one  that  we  have,  and 
in  its  special  adaptation  to  American  practitioners  it 
certainly  has  no  equal. — iV«w  York  Med.  Record, 
Jiai-ch  2,  1868. 

No  other  treatise  on  this  subject  is  better  adapted 
to  the  American  physician.   Dr.  Condie  has  long  stood 


JJ/'EST  [CHARLES),  M.D., 

'  '  Physician  to  the  Hospital  for  Sick  Children,  Ac. 

LECTURES  ON  THE   DISEASES   OP  INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  and  enlarged  English  edition.  In  one 
large  and  handsome  octavo  volume  of  656  closely-printed  pages.  Extra  cloth,  $'1  50 ; 
leather,  $5  60.     (Lately  issued.) 

Dr.  West's  volume  is,  in  onr  opinion,  incomparably 
the  best  authority  upon  the  maladies  of  children 
that  the  practitioner  can  con.salt. — Cincinnati  Jour, 
of  Medicine,  March,  1866. 

We  have  long  regarded  it  as  the  most  scientific  and 
practical  book  on  diseases  of  children  which  ha.s  yei 
appeared  in  this  coantry. — Buffalo  Medical  Journal. 


Of  all  the  English  writers  on  the  diseases  of  chil- 
dren, there  is  no  one  so  entirely  satisfactorj'  to  us  as 
Dr.  West.  For  years  we  have  held  his  opinion  as 
judicial,  and  have  regarded  him  as  one  of  the  highest 
living  authorities  in  the  difficult  department  of  medi- 
cal science  in  which  he  is  most  widely  known. — 
Boston  Med.  and  Surg.  Journal,  April  26,  1866. 


^MITH  [E  USTA  CE),  M.  D., 

Physician  to  the  l^orthwest  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE   ON   THE  WASTING  DISEASES  OF 

INFANCY  AND  CHILDHOOD.     1  vol.  8vo.     Second  and  revised  edition.     (Prtpariug.) 

a  purpose  of  clinical  usefulness,  he  has  succeeded  In 
producing  a  treatise  on  the  causes  of  chronic  wasting 
so  complete  that  but  little  could  be  added,  and  yet  so 
concise  that  it  would  be  almost  impossible  to  give  a 


In  this  brief  treatise,  the  author  has  made  one  of 
the  most  valuable  contributions  to  medical  literature 
that  has  been  given  to  our  profession  for  many  years. 
To  supply  the  want  of  information  on  this  subject  is 
the  task  which  Dr.  Smith  has  set  himself,  and  admi- 
rably has  he  performed  it.     Keeping  steadily  in  view 


synopsis  of  his  views  in  fewer  words  than  the  book 
itself  contains.— X  T.  Med.  OazMe,  April  2,  1870. 


D 


EWEES  {WILLIAM  P.),  M.D. 

A  TREATISE  ON  THE  PHYSICAL  AND  MEDICAL  TREAT- 
MENT OF  CHILDREN.  Eleventh  edition,  with  the  author's  last  improvements  and  cor- 
rections.    In  one  octavo  volume  of  548  pages.     $2  80. 


22 


Henry  C.  Lea's  Publications — {Diseases  of  Women). 


ffHOMAS  {ZGAILLARD),M.D., 

-L  PriifkSKor  of  Obstetrics,  &c  in  the  Cdlege  of  Phyfticianft  and  Surgeons,  N.  T.,  Ac. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Se- 

cond  edition,  revised  and  improved      In  one  large  and  handsome  octavo  volume  of  650 
pages,  with  225  illustrations,  extra  cloth,  $5;  le.other,  $6.     {Just  Issued.} 
From  tJie  Preface  to  the  Second  Edition. 
In  a  science  so  rapidly  progressive  as  that  of  medicine,  the  profession  has  a  right  to  expect  that, 
when  its  approbation  of  a  work  is  manifested  by  a  call  for  a  new  edition,  the  author  should  re- 
spond by  giving  to  his  book  whatever  of  additional  value  may  be  derivable  from  more  extended 
experience,   matiirer  thought,   and  the  opportunity  for  correction.     Fully  sensible  of  this,   the 
a«thor  of  the  present  volume  has  sought  by  a  careful  revision  of  the  whole,  and  by  the  additipn 
of  a  chapter  on  Chlorosis,  to  render  his  work  more  worthy  of  the  favor  with  which  it  has  been 
received. — New  York,  March,  1869. 


If  the  excellence  of  a  work  is  to  be  judged  by  its 
rapid  sale,  this  one  ranst  tiike  precedence  «f  all  otbers 
npoa  the  ?ame,  or  kindred  subjects,  as  evidencpd  in 
the  shiirt  time  from  its  first  appearance,  in  which  a 
new  edition  is  called  for,  resulting,  as  we  are  informed, 
from  the  exhaustion  of  the  previous  large  edilion.  We 
deem  it  scarcely  necessery  to  recommend  this  work 
to  phy.sicians  as  it  is  now  widely  known,  and  most 
of  them  already  possess  it,  or  will  certainly  do  so. 
To  students  we  unhesitatingly  recommend  it  as  the 
best  text-book  on  diseases  of  females  extant.— jSt.Xowi* 
Med.  Reporter,  June,  1869. 

Of  all  the  army  of  books  that  have  appeared  of  late 
years,  on  the  diseases  of  the  uterus  and  its  appendages, 
we  know  of  none  that  is  so  clear,  comprehensive,  and 
practical  as  this  of  Dr.  Thomas',  or  one  that  we  should 
more  emphatically  recommend  to  the  young  practi- 
tioner, as  his  guide. — California  Med.  Gazette,  June, 
1869. 

If  not  the  best  work  extant  on  the  subject  of  which 
it  treats,  it  is  certainly  second  to  none  other.  So 
short  a  time  has  elapsed  since  the  medical  press 
teemed  with  commendatory  notices  of  the  first  edition, 
that  it  would  be  superfluous  to  give  an  extended  re- 
view of  what  is  now  firmly  established  as  </i«  American 
text-book  of  (Synajcology. — N.  T.  Med.  Gazette,  July 
17,  1869. 

This  is  a  new  and  revised  edition  of  a  work  which 
we  recently  noticed  at  some  length,  and  earnestly 
commended  to  the  favorable  attention  of  our  readers. 
The  fact  that,  in  the  short  space  of  one  year,  this 
second  edition  makes  its  appearance,  shows  that  the 
general  judgment  of  the  profession  has  largely  con- 
firmed the  opinion  we  gave  at  that  time. — Cincinnati 
Lancet,  Aug.  1869. 

It  is  so  short  a  time  since  we  gave  a  full  review  of 
the  first  edition  of  this  book,  that  we  deem  it  only 
necessary  now  to  call  attention  to  the  second  appear- 
ance of  the  work.  Its  success  has  been  remarkable, 
and  we  can  only  congratulate  the  author  on  the 
brilliant  reception  his  book  has  received.— iv;  T.  Med. 
Journal,  April,  1869. 


We  regard  this  treatise  as  the  one  best  adapted  to 
serve  as  a  text-book  on  gynzecology. — St.  Louis  Med. 
and  Surg.  Journal,  May  10,  1869." 

The  whole  work  as  it  now  stands  is  an  absolute 
indispensable  to  any  physician  aspiring  to  treat  the 
diseases  of  females  with  success,  and  according  to  the 
most  fally  accepted  views  of  their  jetiology  and  pa- 
thology.— Leavenworth  Medical  Uerald,  iNIay,  1869. 

We  have  seldom  read  a  medical  book  in  which  we 
found  so  much  to  praise,  and  so  little — we  can  hardly 
say  to  object  to — to  mention  with  qualified  commen- 
dation. We  had  proposed  a  somewhat  extended 
review  with  copious  extracts,  but  we  hardly  know 
where  we  should  have  space  for  it.  We  therefoi-e 
Content  ourselves  with  expressing  the  belief  that 
every  practitioner  of  medicine  would  do  well  to  pos- 
sess himself  of  the  work. — Boston  Med.  and  Surg. 
■Tournul,  April  29,  1869. 

The  number  of  works  published  on  diseases  of 
women  is  large,  not  a  few  of  which  are  very  valuable. 
But  of  those  which  are  the  most  valuable  we  do  not 
regard  the  work  of  Dr.  Thomas  as  second  to  any. 
Without  being  proli.x,  it  treats  of  the  disorders  to 
which  it  is  devoted  fully,  perspicuously,  and  satisfac- 
torily. It  will  be  found  a  treasury  of  knowledge  to 
every  physician  who  turns  to  its  pages.  We  would 
like  to  make  a  number  of  quotations  from  the  work 
of  a  practical  bearing,  bat  our  space  will  not  permit. 
The  work  should  lind  a  place  in  the  libraries  of  all 
physicians. — Cincinnati  Med.  Repertory,  May,  1869. 

No  one  will  be  surprised  to  learn  that  the  valuable, 
readable,  and  thoroughly  practical  book  of  Professor 
Thomas  has  so  soon  advanced  to  a  second  edition. 
Although  very  little  time  has  necessarily  been  allowed 
our  author  for  revision  and  improvement  of  the  work, 
he  has  performed  it  exceedingly  well.  Aside  from 
the  numerous  corrections  which  he  has  found  neces- 
sary to  make,  he  has  added  an  admirable  cliapter  on 
chlorosis,  which  of  itself  is  worth  the  cost  of  th« 
volume.— JV.  r.  Med.  Record,  May  15,  1869. 


fJHURGHILL  [FLEETWOOD),  M.  D.,  M.  R.  I.  A. 

ON  THE  DISEASES    OF  WOMEN;    including  those  of  Pregnancy 

and  Childbed.    A  new  American  edition,  revised  by  the  Author.    With  Notes  and  Additions, 
by  D.  PRANcrs  Condib,  M.  D.,  author  of  "  A  Practical  Treatise  on  the  Diseases  of  Chil- 
dren."    With  numerous  illustrations.      In  one  large  and  handsome  octavo  volume  of  7&8 
pages,  extra  cloth,  $4  00;  leather,  $5  00. 
D  r  THE  SAME  AUTHOR.  

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DIS- 
EASES PECULIAR  TO  WOMEN.  Selected  from  the  writings  of  British  Authors  previ- 
ous to  the  close  of  the  Eighteenth  Century.  In  one  neat  octavo  volume  of  about  450 
pages,  extra  cloth.     $2  50. 

ASH  WELL  [SAMUEL],  M.D., 

-^^  Late  Obstetric  Physician  and  Lecturer  at  Guy's  Bospital. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO 

WOMEN.     Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.     Third  .Ame- 
rican, from  the  Third  and  revised  London  edition.     In  one  octavo  volume,  extra  cloth,  of 
»  628  pages.     $3  50. 


BROWN  ON  SOME  DISEASES  OF  WOMEN  AD- 
MITTING OF  SURGICAL  TREATMENT.  With 
handsome  illustrations.  One  volume  8vo.,  extra 
cloth,  pp.  276.     $]  60. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES.    With  illustrations.     Eleventh  Edition, 


with  the  Author's  last  improvements  and  correc- 
tions. In  one  octavo  volume  of  638  pages,  with 
plates,  extra  cloth,  $3  00. 
RIGBY  ON  THE  CONSTITUTIONAL  TREATMENT 
OF  FEMALE  DISEASES.  In  one  neat  royal  l'2mo. 
volume,  extra  cloth,  of  about  2o0  pages.    $1  Ou. 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


23 


JJODGE  {HUGH  L.),  M.D., 

-*■-*-  Emeritus  ProftSHor  of  OMdrics,  i-c,  in  the  University  of  Pennsylvania. 

•       OX  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.  With  original  illustrations.  Second  edition,  revi.^ed  and-  enlarj^ed.  In 
one  beautifully  printed  octavo  volume  of  531  pages,  extra  cloth.  $4  50.  {Just  Issued.) 
In  the  preparation  of  this  edition  the  author  has  spared  no  pains  to  improve  it  with  the  results 
of  his  observation  and  study  during  the  interval  which  has  elapsed  since  the  first  appearance  of 
the  work.  Considerable  additions  have  thus  been  made  to  it,  which  have  been  partially  accom- 
modated by  an  enlargement  in  the  size  of  the  page,  to  avoid  increasing  unduly  the  bulk  of  the 
volume. 


From  Peop^  W.  H.  Btford,  of  the  Bush  Medical 
College,  Chicago. 

The  book  bears  the  impress  of  a  master  hand,  and 
must,  as  its  predecessor,  prove  acceptable  to  the  pro- 
fession. In  diseases  of  women  Dr.  Hodge  has  estab- 
lished a  school  of  treatment  that  has  become  world- 
wide in  fame. 

Professor  Hodge's  work  is  truly  an  original  one 
from  beginning  to  end,  consequently  no  one  can  pe- 
ruse its  pages  without  learning  something  new.  The 
book,  which  is  by  no  means  a  large  one,  is  divided  into 
two  grand  sections,  so  to  speak  :  first,  that  treating  of 
the  nervous  sympathies  of  the  uterus,  and,  secondly, 
that  which  speaks  of  the  mechanical  treatment  of  dis- 
placements of  that  organ.  He  i.s  disposed,  as  a  non- 
i)eUever  in   the  frequency  of  inflammations  of  the 


uterus,  to  take  strong  ground  against  many  of  the 
highest  authorities  in  this  branch  of  medicine,  and 
the  arguments  which  he  offers  in  support  of  his  posi- 
tion are,  to  say  the  least,  well  put.  Numerous  wood- 
cuts adorn  this  portion  of  the  work,  and  add  incalcu- 
lably to  the  proper  appreciation  of  the  variou.sly 
shaped  instruments  referred  to  by  our  author.  As  a 
contribution  to  the  study  of  women"*  diseases,  it  is  of 
great  value,  and  is  abundantly  able  to  stand  on  its 
own  merits. — y.  T.  Medical  Record,  Sept.  15,  1868. 

In  this  point  of  view,  the  treatise  of  Professor 
Hodge  will  be  indispensable  to  every  student  in  its 
department.  The  large,  fair  type  and  general  perfec- 
tion of  ^vorkmanship  will  render  it  doubly  welcome. 
— Pacific  Med.  and  Surg.  Journal,  Oct.  1S68. 


TyEST  {CHARLES),  M.D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  extra 

cloth.     $3  75;  leather,  $4  75.      {Just  Issued.) 
The  reputation  which  this  volume  has  acquired  as  a  standard  book  of  reference  in  its  depart- 
ment, renders  it  only  necessary  to  say  that  the  present  edition  has  received  a  careful  revision  at 
the  hands  of  the  author,  resulting  in  a  considerable  increase  of  size.     A  few  notices  of  previous 
editions  are  subjoined. 


The  manner  of  the  author  is  excellent,  his  descrip- 
tions graphic  and  perspicuous,  aiid  his  treatment  up 
to  the  level  of  the  time— clear,  precise,  definite,  and 
marked  by  strong  common  sense.  —  Chicago  Med. 
Journal,  Dec.  1861. 

We  cannot  too  highly  recommend  this,  the  second 
edition  of  Dr.  West's  excellent  lectures  on  the  dis- 
eases of  females.  We  know  of  no  other  book  on  this 
subject  from  which  we  have  derived  as  ranch  pleasure 
and  instruction.  Every  page  gives  evidence  of  the 
honest,  earnest,  and  diligent  searcher  after  truth.  He 
is  not  the  mere  compiler  of  other  men's  ideas,  but  his 
lectures  are  the  result  often  years'  patient  investiga- 
tion in  one  of  the  widest  fields  for  women's  diseases — 
St.  Bartholomew's  Hospital.  As  a  teacher.  Dr.  West 
is  simple  and  earnest  in  his  language,  clear  and  com- 
prehensive in  his  perceptions,  and  logical  in  his  de- 
ductions.— Cincinnati  Lancet,  Jan.  1S62. 

We  return  the  author  our  grateful  thanks  for  the 
vast  amount  of  instruction  he  has  afforded  us.  His 
valuable  treatise  needs  no  eulogy  ou  our  part.  His 
graphic  diction  and  truthful  pictures  of  disease  all 
speak  for  themselves. — Medico-Ohirurg.  Review. 

Most  justly  esteemed  a  standard  work It 

bears  evidence  of  having  been  carefully  revised,  and 
is  well  worthy  of  the  fame  it  has  already  obtained. 
— IHib.  Med.  Quar.  Jour. 

or  THE  SAME  AUTHOR.  

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF 

ULCERATION  OF  THE  OS  UTERI.     In  one  neat  octavo  volume,  extra  cloth.     $1  25. 


As  a  writer.  Dr.  West  stands,  in  our  opinion,  se- 
cond only  to  Watson,  the  "Macaulay  of  Medicine;" 
he  possesses  that  happy  faculty  of  clothing  instruc- 
tion in  easy  garments;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro- 
verb, along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
it  is  one  that  will  please  the  great  majority  who  are 
seeking  truth,  and  one  that  will  convince  the  student 
that  he  has  committed  himself  to  a  candid,  safe,  and 
valuable  guide.— iV^  A.  Med. -Chirurg  Review. 

We  must  now  conclude  this  hastily  written  sketch 
with  the  confident  assurance  to  our  readers  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking,  practical  physician  is  apparent  on  every 
page. — N.  Y.  Journal  of  Medicine. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  fucilt.  princeps  of 
British  obstetric  a,Viihois.— Edinburgh  Mtid.  Journal. 

We  gladly  recommend  his  lectures  as  in  the  highest 
degree  instructive  to  all  who  are  interested  in  ob- 
stetric practice. — London.  Lancet. 

We  know  of  no  treatise  of  the  kind  so  complete, 
and  yet  so  compact.— C'Aicafiro  Mtd.  Journal. 


MEIGS  {CHARLES  D.),M.D., 

JjL  Lnte  Professor  of  Obstetrics,  &c.  in  Jefferson  Medical  College,  Philadelphia. 

WOMAN:    HER  DISEASES  AND  THEIR  REMEDIES.     A  Series 

of  Lectures  to  his  Class.     Fourth  and  Improved  edition.     In  one  large  and  beautifully 
printed  octavo  volume  of  over  700  pages,  extra  cloth,  $5  00  j  leather,  $6  00. 
Dr  TBE  SAME  AUTHOR.  — — 

ON  THE  NATURE,  SIGNS,  AND  TREATMENT  OF  CHILDBED 

FEVER.     In  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.     In  one  handsome 
octavo  volupie  of  365  pages,  extra  cloth.     $2  00. 

QL\fPSON  {SIR  JAMES  F.),  M.D. 
CLINICAL  LECTURES  ON  THE  DISEASES  OF  WOMEN.    With 

nuiaerous  illustrations.  In  one  octavo  volume  of  over  500  pages.   Second  edition, ^rf/'o/'i "5-. 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


JJODGE  {HUGH  L.),  M.  D., 

Emeritus  Professor  of  Midwifery,  &c.  in  the  University  of  Pennsylvania,  &e. 

THE   PRINCIPLES  AND   PRACTICE   OF   OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and"  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  extra  cloth,  $14.  (Lately 
published.) 


The  work  of  Dr.  Hodge  is  something  more  than  a 
simple  presentation  of  his  particular  views  in  the  de- 
partment of  Obstetrics  ;  it  is  something  more  than  an 
ordinary  treatise  on  midwifery ;  it  is,  in  fact,  a,  cyclo- 
paedia of  midwifery.  He  has  aimed  to  embody  in  a 
single  volume  the  whole  science  and  art  of  Obstetrics. 
An  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 
is  left  unstated  or  unexplained. — Am,  Med.  Times, 
Sapt.  3,  1S64. 

We  should  like  to  analyze  the  remainder  of  this 
excellent  work,  but  already  has  this  review  extended 
beyond  our  limited  space.  We  cannot  conclude  this 
notice  without  referring  to  the  excellent  finish  of  the 
work.  In  typography  it  is  not  to  be  excelled ;  the 
paper  is  superior  to  what  is  usually  afforded  by  our 
American  cousins,  quite  equal  to  the  best  pf  English 
books.  The  engravings  and  lithographs  are  most 
beautifully  executed.  The  work  recommends  itself 
for  its  originality,  and  is  in  every  way  a  most  valu- 
able addition  to  those  on  the  subject  of  obstetrics. — 
Canada  Med.  Journal,  Oct.  1864. 

It  is  very  large,  profu.sely  and  elegantly  illustrated, 
and  is  fitted  to  take  its  place  near  the  works  of  great 
obstetricians.  Of  the  American  works  on  the  subject 
it  is  decidedly  the  best. — Edinb.  Med.  Jour.,  Dec.  '64. 

***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


We  have  examined  Professor  Hodge's  work  with 
great  satisfaction ;  every  topic  is  efaborated  most 
fully.  The  views  of  the  author  are  comprehensive, 
and  concisely  stated.  The  rules  of  practice  are  judi- 
cious, and  will  enable  the  practitioner  to  meet  every 
emergency  of  obstetric  complication  with  confidence. 
— Clticago  Med.  Journal,  Aug.  1864. 

More  time  than  we  have  had  at  our  di.'jposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacific 
Med.  and  Surg.  Journal,  July,  1664. 

We  have  read  Dr.  Hodge's  book  with  great  plea- 
sure, and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.  It  is  certainly  highly 
instructive,  and  in  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  alo%g  with  the  con- 
clusions at  which  he  has  arrived,  point,  we  tbiak, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


fJlANNER  [THOMAS  R.),  M.  D. 
ON  THE  SIGNS  AND  DISEASES  OP  PREGNANCY.     FIr.st  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustrations 
on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $4  25.     (Just 
Issued.) 
The  very  thorough  revision  the  work  has  undergone  i  state  even,  acceptable  to  the  profession.     We  recom- 


has  added  greatly  to  its  practical  value,  and  increased 
materially  its  efficiency  as  a  guide  to  the  student  and 
to  the  young  practitioner. — Am.  Journ.  Med.  Sci., 
April,  1S6S. 

With  the  immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im- 
possibility of  giving  an  extended  review  of  thip  truly 
remarkable  work  must  be  apparent.  We  have  not  a 
single  fault  to  flad  with  it,  and  most  heartily  com- 
mend it  to  the  careful  study  of  every  physician  who 
would  not  only  always  be  sure  of  his  diagnosis  of 
pregnancy,  but  always  ready  to  treat  all  the  nume- 
rous ailments  that  are,  unfortunately  for  the  civilized 
women  of  to-day,  so  commonly  associated  with  the 
function.— i^'.  Y.  Med.  Record,  March  16,  1868. 

We  have  much  pleasure  in  calling  the  attention  of 
our  readers  to  the  volume  produced  by  Dr.  Tanner, 
the  second  edition  of  a  work  that  was,  in  its  original 


mend  obstetrical  students,  young  and  old,  to  have 
this  volume  in  their  collections.  It  contains  not  only 
a  fair  statement  of  the  signs,  symptoms,  and  diseases 
of  pregnancy,  but  comprises  in  addition  much  inter- 
esting relative  matter  that  is  not  to  be  found  in  any 
other  work  that  we  can  name. — Edinburgh  Med. 
Journal,  Jan.  1868. 

In  its  treatment  of  the  signs  and  diseases  of  preg- 
nancy it  is  the  most  complete  hook  we  know  of, 
abounding  on  every  page  with  matter  valuable  to  the 
general  practitioner. — Cincinnati  Med.  Repertory, 
March,  1868. 

This  is  a  most  excellent  work,  and  should  be  on  the 
table  or  in  the  library  of  every  practitioner. — Hum- 
boldt Med.  Archives,  Feb.  1868. 

A  valuable  compendium,  enriched  by  his  own  la- 
bors, of  all  that  is  known  on  the  signs  and  diseases  of 
pregnancy. — St.  Louis  Med.  RepoHer,  Feb.  15,  1868. 


M 


0NTG0MER7  (W.  F.),  M.D., 

Professor  of  Midwifery  in  Vie  Kiiig's  and  Queen's  College  of  Physicians  in  Ireland. 


AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREG- 

NANCY.  With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second 
and  enlarged  English  edition.  With  two  exquisite  colored  plates,  and  numerous  wocd-cuta. 
In  one  very  handsome  octavo  volume  of  nearly  600  pages,  extra  cloth.     %'6  lb. 


M 


ILLER  [HENRY),  M.D., 

Professor  of  Ohstetries  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 


PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c.;  including 

the  Treatment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered 
as  a  frequent  cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  one 
very  handsome  octavo  volume  of  over  600  pages,  extra  cloth.     $3  76. 


BIGHT'S  SYSTEM  OF  MIDWIFERY.  With  Notes 
and  Additional  Illustrations.  Second  American 
edition.  One  volume  octavo,  extra  cloth,  422  pages. 
12  50. 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY. Twelfth  edition,  with  the  author's  last 
improvements  and  corrections.  In  one  octavo  vol- 
ume, extra  cloth,  of  600  pages.    $3  60. 


Henry  C.  Lea's  Publications — {Midwifery). 


25 


lUTEIGS  {CHARLES  D.),  M.D., 

■*•"■  Lately  Professor  of  OhHetrics,  &c  ,  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS:   THE   SCIEXCE   AND  THE   ART.     Fifth  edition, 

revised.     With  one  hundred  and  thirty  illustrations.     In  one  beautifully  printed  octavo 
volume  of  760  large  pages.     Extra  cloth,  $5  50;  leather,  $6  50.      {Just  Issued.) 


It  Is  to  the  student  that  our  author  has  more  par- 
ticularly addressed  himself;  but  to  the  practitioner 
we  believe  it  would  be  equally  serviceable  as  a  book 
Qf  reference  No  work  that  we  have  met  with  so 
thoroughly  details  everythitjg  that  falls  to  the  lot  of 
the  accoucheur  to  perform.  Every  detail,  no  matter 
how  minute  or  how  trivial,  has  found  a  place.— 
Canada  MedicalJournul,  July,  1S67. 

The  original  edition  is  already  so  extensively  and 


favorably  known  to  the  profession  that  no  recom- 
mendation is  necessary;  it  is  suflicient  to  say,  the 
present  edition  is  very  much  extended,  improved, 
and  perfected.  Whilst  the  great  practical  talents  and 
unlimited  experience  of  the  author  reader  it  a  most 
valuable  acquisition  to  the  practitioner,  it  is  so  con- 
densed as  to  constitute  a  most  eligible  and  excellent 
text- book  for  the  student. — Southern  Med.  and  Surg, 
journal,  July,  1867. 


DAMSBOTHAM  {FRANCIS  H.),  M.D. 
THE  PRINCIPLES   AND    PRACTICE   OF   OBSTETRIC  MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  Ac,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo, volume  of  660  pages,  strongly  bound  in  leather,  with  raised 
bands ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 

To  the  physician's  library  it  is  Indispensable,  while 
to  the  student,  as  a  text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  ed  ucation 
on  obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  .Journnl. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a  knowledge  of  this  subject,  we  canuot  but 
envy  the  student  of  the  present  day  the  aid  which 
this  work  will  afford  him. — Am.  Jour,  of  the  Med. 
Sciences. 


We  will  only  add  that  the  student  will  learn  from 
It  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethofico'pe. 

The  character  and  merits  of  Dr.  Ramsbotham's 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louis  Med.  and  Surg.  Journal. 


/JHURCHILL  {FLEETWOOD),  M.D.,  M.R.LA. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.     M'ith  notes  and  additions 
by  D.  Fbancis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren,'' Ac.     With  one  hundred  and  ninety- four  illustrations.     In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Extra  cloth,  $4  00;  leather,  $6  00. 
In  adapting  this  standard  favorite  to  the  wants  of  the  profession  in  the  United  States,  the  editor 
has  endeavored  to  insert  everything  that  his  experience  has  shown  him  would  be  desirable  for  the 
American  student,  including  a  large  number  of  illustrations.     With  the  sanction  of  the  author, 
he  has  added,  in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and 
Nurses,"  recently  issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  fan  hardly 
fail  to  prove  of  advantage  to  the  junior  practitioner.     The  result  of  all  these  additions  is  that  the 
work  now  contains  fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one- 
half  more  illustrations ;  so  that,  notwithstanding  the  use  of  a  sihaller  type,  the  volume  contains 
almost  two  hundred  pages  more  than  before. 

has  been  added  which  could  be  well  dispensed  with. 
An  examination  of  the  table  of  contents  shows  how 
thoroughly  the  author  has  gone  over  the  ground,  and 
the  care  he  has  taken  in  the  text  to  present  the  sub- 
jects in  all  their  bearings,  will  render  this  new  edition 
even  more  necessary  to  the  obstetric  student  than 
were  either  of  the  former  editions  at  the  date  of  their 
appearance.  No  treatise  on  obstetrics  with  which  we 
are  acquainted  can  compare  favorably  with  this,  in 
respect  to  the  amount  of  material  which  bus  been 
gathered  from  every  source. — Boston  Mtd.  and  Surg. 
Journal. 


These  additions  render  the  work  still  more  com- 
plete and  acceptable  than  ever;  and  with  the  excel- 
lent style  in  which  the  publishers  have  presented 
this  edition  of  Churchill,  we  can  commend  it  to  the 
profession  with  great  cordiality  and  pleasure. — Cin- 
cinnati Lancnt. 

Few  worke  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice,  and  in  one  respect  it  is  superior 
to  all  others,  viz.,  in  its  statistical  information,  and 
therefore,  on  these  grounds  a  most  valuable  work  for 
the  physician,  student,  or  lecturer,  all  of  whom  will 
find  in  it  the  information  which  they  are  seeking. — 
Brit.  Am.  Journal. 

The  present  treatise  is  very  much  enlarged  and 
araplifled  beyond  the  previous  editions  but  nothing 


There  is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practisiut;  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Jottrnal. 


<;^ WAYNE  {JOSEPH  GRIFFITHS),  31.  B., 

f^  Physician-Accoucheur  to  the  British  General  Hospital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE.     From  the  Fourth  and  Revised  London  Edition, 
with  Additions  by  E.  R.   Hutchins,  M.  D.     With  Illustrations.     In  one  neat  12mo.  vol- 
ume.    Eztra  cloth,  $1  25.      (Just  Issued.) 
It  is  really  a  capital  little  compendium  of  the  sub- 


ject, and  we  recommend  young  praciitiouers  to  buy  it 
and  carry  it  with  them  when  called  to  attend  cases  of 
labor,  i'hey  can  while  away  the  otherwise  tedious 
hours  of  waiting,  and  thoroughly  fix  in  their  memo- 
ries the  most  important  practical  suggestions  it  con- 
tains. The  American  editor  has  materially  added  by 
his  notes  and  the  concluding  chapters  to  the  com- 


pleteness and  general  value  of  the  book. — Chicago 
Med.  Journal,  Feb.  1S70. 

The  manual  before  us  contains  in  exceedinglj*  small 
compass — small  enough  to  carry  in  the  pucket — about 
all  there  is  of  obstetrics,  conden.ned  into  a  nutshell  of 
Aphorisms.  The  illustrations  are  well  selected,  and 
serve  as  excellent  reminders  of  the  conduct  of  labor — 
regular  aud  difficult.  —  Cincinnati  iance<,April,  '70. 


26 


Henry  C.  Lea's  Publications — (Surgery). 


QROSS  {SAMUEL  D.),  M.D.,     ■ 

ProfesKor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.  Illustrated  by  upwards  of  Thirteen  Hundred  Engravings.  Fourth  edition, 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  royal  octavo  volumes 
of  2200  pages,  strongly  bound  in  leather,  with  raised  bands.     $15  00. 

The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioqers  and  students.  Though 
but  little  over  six  years  have  elapsed  since  its  first  publication,  it  has  already  reached  its  fourtli 
edition,  while  the  care  of  the  author  in  its  revision  and  correction  has  kept  it  in  a  constantly  im- 
proved shape.  By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.  This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding, 
renders  it  one  of  the  cheapest  works  accessible  to  the  profession.  Every  subject  properly  belonging 
to  the  domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be 
said  to  have  in  it  a  surgical  library. 


It  must  long  remain  the  most  comprehensive  work 
on  this  important  part  of  medicine. — Boston  Medical 
and  Surgical  Journal,  March  2.3,  1865. 

We  have  compared  it  with  most  of  our  standard 
Works,  such  as  those  of  Brichsen,  Miller,  Fergusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a  work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  subject  known  in 
the  principles  and  prPvCtice  of  surgery,  we  believe  it 
Btands  without  a  rival.  Dr.  Gross,  in  his  preface,  re- 
marks "my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;"  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confidently  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  the  shelves  of  our  library.— Canada  Med. 
Journal,  September,  I860.         • 

The  first  two  editions  of  Professor  Gross'  System  of 
Sm-gery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work. —  Chicago  Medical  Journal, 
September,  1S65. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  first  appearance. — British 
and  Foreign  Medioo-Ohirurgical  Review,  Oct.  I860. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera- 
ture, and  be  the  crowning  glory  of  the  author's  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-eminent 
place,  not  only  at  home,  but  abroad.  We  have  no 
hesitation  in  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
any  language. — N.  Y.  Med.  Journal. 

Not  only  by  far  the  best  text-book  on  the  subject, 
as  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a  high  authority 
abroad. — Am.  Jonrnal  Med.  Sciences,  Jan.  ISe.*). 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and   .)poralions.     It  is  a  complete  Tliesaurus 


tioner  shall  not  seek  in  vain  for  what  they  desire.— 
San  Francisco  Med.  Press,  Jan.  186.'5. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  or  even  national  system  of  sur- 
gery, but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med.  Journal, 
Jan.  IS60. 

A  glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  complete  "System  of  Surgery"  ever  pub- 
lished in  any  country. — St.  Louis  Med.  and  Surg 
Journal,  April,  1S6.5. 

The  third  opportunity  Is  now  oflfered  during  our 
editorial  life  to  review,  or  rather  to  indorse  and  re- 
commend this  great  American  work  on  Surgery. 
Upon  this  last  edition  a  great  amount  of  labor  has 
been  expended,  though  to  all  others  except  the  author 
the  work  was  regarded  in  its  previous  editions  as  SO 
full  and  complete  as  to  be  hardly  capable  of  improve- 
ment. Every  chapter  has  been  revised ;  the  text  aug- 
jnented  by  nearly  two  hundred  pages,  and  a  con- 
siderable number  of  wood-cuts  have  been  introduced. 
Many  portions  have  been  entirely  re-writ len,  and  the 
additions  made  to  the  text  are  principally  of  a  prac- 
tical character.  This  comprehensive  treatise  upon 
surgery  has  undergone, revisions  and  enlargements, 
keeping  pace  with  the  progress  of  the  art  and  science 
of  surgery,  so  that  whoever  is  in  possession  of  this 
work  may  consult  its  pages  upon  any  topic  embraced 
within  the  scope  of  its  department,  and  rest  satisfied 
that  its  teaching  is  fully  up  to  the  present  standard 
of  surgical  knowledge.  It  is  also  so  comprehensive 
that  it  may  truthfully  be  said  to  embrace  all  that  is 
actually  known,  that  is  really  of  any  value  in  the 
diagnosis  and  treatment  of  surgical  diseases  and  acci- 
dents. Wherever  illustration  will  add  clearness  to'the 
subject,  or  make  better  or  more  lasting  impression,  it 
is  not  wanting:  in  this  respect  the  work  is  eminently 
superior. — Buffalo  Med.  Journal,  Dec.  1864. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  surgical  .>icieuce.  And  wliat,  in  our  opin- 
ion, enhances  the  value  of  the  work  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  i^  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  aud  practice  of  this 
branch  of  the   profession  which    he  designs  subse- 


of  modern  turgery,  where  the  student  and  practi-    quently  to  follow. — Tfie  Brit.  Am.  Journ.,  Montreal. 


or  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE    ON    FOREIGN    BODIES   IN   THE 

AIR-PASSAGES.       In   one  handsome  octavo  volume,   extra  cloth,   with  illustrationp. 
pp.  468.     $2  75. 


MALGAIGNE'S  OPERATITE  SUROERT.  With  nu- 
merous illn^tratil..ns  on  wo^id  In  one  handsome 
octavo  volume,  extra  cloth,  of  nearly  600  pp.    fi2  50. 


SKET'S  OPERATIVE  SURGEP.T.  In  one  v«.ry  hand- 
some octavo  volume,  extra  cloth,  of  over  bii'J  jagee 
with  about  100  wood-cats.    $S  26. 


Henry  C.  Lea's  Publications — (Surgery).  27 

PRICHSEN  [JOHN), 

-*-•  Senior  Surgeon  to  Univergity  Cnlhge  Hnsjiitnl. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Siir- 

gical  Injuries,  Diseases,  and  Operations.     From  the  Fifth  enlarged  and  carefully  revised 

London  Edition.     With  Additions  by  John  Asiihukst,  Jr.,  M.  D.,  Surgeon  to  the  Episcopal 

Hospital,  Ac.      Illustrated  by  over  six  hundred  Engravings  on  wood.     In  one  very  large 

and  beautifully  printed  imperial  octavo  volume,  containing  over  twelve  hundred  closely 

printed  pages  :  cloth,  $7  50  ;  leather,  raised  bands,  $8  50.     (Just  Issued.) 

This  volume  having  enjoyed  repeated  revisions  at  the  hands  of  the  author  has  been  greatly 

enlarged,  and  the  pre.sent  edition  will  thus  be  found  to  contain  at  least  one-half  mo.re  matter  than 

the  last  Am'erican  impression.     On  the  latest  London  edition,  just  issued,  especial  care  has  been 

bestowed.     Besides  the  most  minute  attention  on  the  part  of  the  author  to  bring  every  portion  of 

it  thoroughly  on  a  level  with  the  existing  condition  of  science,  he  called  to  his  aid  gentlemen  of 

distinction  in  special  departments.     Thus  a  chapter  on  the  Surgery  of  the  Eye  and  its  Appendages 

has  been  contributed  by  Mr.  Streatfeild  ;  the  section  devoted  to  Syphilis  has  been  rearranged 

under  the  supervision  of  Mr.  Berkeley  Hill  ;  the  subjects  of  General  Surgical  Diseases,  including 

Pyaemia,  Scrofula,  and  Tumors,  have  been  revised  by  Mr.  Alexander  Bruce  ;  and  other  professional 

men  of  eminence  have  assisted  in  other  brunches.     The  work  may  thus  bo  regarded  as  eniljodying 

a  complete  and  comprehensive  view  of  the  most  advanced  condition  of  British  surgery  ;  while 

such  omissions  of  practical  details  in  American  surgery  as  were  found  have  been  supplied  by  the 

editor,  Dr.  Ashhurst. 

Thus  complete  in  every  respect,  thoroughly  illustrated,  and  containing  in  one  beautifully  printed 
Tolume  the  matter  of  two  or  three  ordinary  octavos,  it  is  presented  at  a  price  which  renders  it 
.one  of  the  cheapest  works  now  accessible  to  the  profession.  A  continuance  of  the  very  remarkable 
favor  which  it  has  thus  far  enjoyed  is  therefore  confidently  expected. 

those  eulightened  surgeons  of  the  present  day,  who 
regard  an  acquaintance  with  the  manual  part  •)f  sur- 
gery as  only  a  portion  of  that  kno^viedge  wliich 


The  high  position  which  Mr.  Erichsen's  Science  and 
Art  of  Surgery  has  for  some  time  attained,  not  only 
in  this  couutry,  but  on  the  Continent  and  in  America, 
almost  limits  the  task  of  the  reviewer,  on  the  appear- 
ance of  a  new  edition,  to  the  mere  announcement. 
Elaborate  analysis  and  criticism  would  be  out  of 
place  ;  and  nothing  remains  to  be  done  except  to  state 
in  general  terms  that  the  author  has  bestowed  on  it 
that  labor  which  such  a  work  required  in  order  to  be 


surgeon  should  possess. — British  Medical  Journal, 
Jan.  2,  1S69. 

Thus  the  work  bears  in  every  feature  a  stamp  of 
novelty  and  freshness  whicli  will  commcud  it  to  those 
who  are  making  its  acquaintance  for  thL>  first  time. 


made  a  representative  of  the  existing  state  of  surgical  whilst  those  who  have  fnund  it  a  sale  guide  and 
science  and  practice.  Of  the  merits  of  the  book  as  a  friend  in  former  years  will  be  able  to  refer  to  the  new 
guide  to  the  "Science  and  Art  of  Surgery''  it  i.-3  not  edition  for  the  latest  information  upon  any  point  of 
necessary  for  ns  to  say  much.     Mr.  Erichseh  is  one  of  '  surgical  controversy. — London  Lancet,  Jan.  23, 1S69. 


or  THE  SAME  AUTHOR.     [Just  Issued.) 

ON   RAILWAY,    AND    OTHER    INJURIES   OF    THE    NERVOUS 

SYSTEM.     In  small  octavo  volume.     Extra  cloth,  $1  00, 


llflLLER  [JJiMES), 

•*-'-*-  £,„(,;  Profe.v.^-or  of  Surgery  in  the  University  of  Edinburgh,  &e. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.     In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth.     $3  75. 
-DY  THE  SAME  AUTHOR.  

THE   PRACTICE   OF   SURGERY.     Fourth  American,  from  the  last 

Edinburgh  edition.     Revised  by  the  American  editor.     Illustrated  by  three  hundred  and 

sixty-four  engravings  on  wood.     In  one  large  octavo  volume  of  nearly  700  pages,  extra 

cloth.     $3  75. 

It  is  seldom  that  two  volumes  have  ever  made  so  I  acquired.    The  anther  is  an  eminently  sensible,  prac- 

profcund  an  impression   in  so   short  a  time   as  the  |  tical,  and  well-informed  man,  who   knows  exactly 

"Principles"  and  the  "Practice"  of  Surgery  by  Mr.     what  he  is  talking  about  and  exactly  how  to  talk  it.— 

Miller,  or  so  richly  merited  the  reputation  they  have  |  Kr.ntucky  Mtdical  Recorder. 


PIRRIE  (  WILLIAM),  F.  R.  S.  E., 
Professor  of  Surgery  in  the  University  of  Aherdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  <fec.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  extra  cloth.     $3  75. 

CI  ARGENT  [F.  W.),  M.D. 

ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SUR- 
GERY. New  edition,  with  an  additional  chapter  on  Military  Surgery.  One  handsome  royal 
12mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.     Extra  cloth,  $1  75. 

We  cordially  commend  this  volume  as  one  which 
the  medical  student  should  most  closely  study  ;  and 
to  the  surgeon  in  practice  it  must  prove  itself  instruct- 


Exceedingly  convenient  and  valuable  to  all  mem- 
bers of  the  profession.— CAtca^o  Mtdical  Examiner, 
May,  1862. 

The  very  best  manual  of  Blinor  Surgery  we  have 
seen. — Buffalo  Medical  Journal. 


ive  on  many  points  which  he  may  have  forgotten. — 
Brit.  Am.  Journal,  May.  1662. 


Henry  C.  Lea's  Publications — (Surgery). 


T^RUITT  [ROBERT),  M.R.C.S.,  ^c. 


THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  reyised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood-engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages.    Extra  cloth,  $4  00  ;  leather,  $5  00. 

All  that  the  surgical  student  or  practitioner  could  theoretical  surgical  opinions,  no  work  that  we  are  at 
desire  — DKhlin  Quarterly  Journal.  \  present  acquainted  with  can  at  all  compare  with  it. 

It  is  a  most  admirable  book.  We  do  not  know  !  Jt  i«  «■  compendium  of  surgical  theory  (if  we  mayus« 
when  we  have  examined  one  with  more  pleasure.-  ^e  word)  and  practice  in  itself  and  well  deserves 
B<,ston  Med.  and  Sur(,.  Joxirnal.  I  ^^^  estimate  placed  upon  it.-Brtt.  Am.  Journal. 

In  Mr.  Druitf  s  book,  though  containing  only  some  '  Tfius  enlarged  and  improved,  it  will  continue  to 
seven  hundred  pages,' both  the  principles  and  the  "^"1^  '^^^JS  ^^  best  text-books  ou  elementary  sur- 
practice  of  surgery  are  treated,  and  so  clearly  and  S^iy.-Columbu.^  Sev.  of  Med.  and  Surg. 
perspicuously,  as  to  elucidate  every  important  topic.  We  must  close  this  brief  notice  of  an  admirable 
The  fact  thattwelve  editions  have  already  been  called  work  by  recommending  it  to  the  earnest  attention  of 
for,  in  these  days  of  active  competition,  would  of  every  medical  student. — Charleston  Medical  Joxirnal 
itself  show  it   to  possess  marked   superiority.     We    and  Review. 

have  examiaed  the  book  most  thoroughly,  and  can  ^  text-book  which  the  general  voice  of  the  profes- 
say  that  this  success  is  well  merited.  His  book,  ^ion  in  both  England  and  America  has  commended  as 
moreover,  possesses  the  inestimable  advantages  of  ^^g  ^f  the  most  admirable  "manuals,"  or,  "w«i« 
having  the  subjects  perfectly  well  arranged  and  clas-  mecum,"  as  its  English  title  runs,  which  can  be 
sified,  and  of  being  written  in  a  style  at  once  clear  pieced  in  the  hands  of  the  student.  The  merits  of 
and  succinct.— -^r/i.  Journal  of  Med.  Sciences.  i  Drujtt's  Surgery  are  too  well  known  to  every  one  to 

Whether  we  view  Druitt's  Surgery  as  a  guide  to  need  any  further  eulogium  from  us. — Nashville  Med. 
operative  procedures,  or  as  representing  the  latest   Journal. 


H 


AMILTON  [FRANK  H.),  M.D., 

Professor  of  Fractures  and  Dislocations,  Ac.  in.  BeUerme  Bosp.  Med.  CciUge,  New  Tor\. 

A  PRACTICAL  TREATISE   ON  FRACTURES  AND   DISLOCA- 

TIONS.     Third  edition,  thoroughly  revised.     In  one  large  and  handsome   octavo  volume 
of  777  pages,  with  294  illustrations,  extra  cloth,  $5  75.     {Just  Issiied.) 


In  fulness  of  detail,  simplicity  of  arrangement,  and 
accuracy  of  description,  this  work  stands  unrivalled. 
So  far  as  we  know,  no  other  work  on  the  subject  in 
the  English  language  can  be  compared  with  it.  While 
congratulating  our  trans-Atlantic  brethren  on  the 
European  reputation  which  Dr.  Hamilton,  along  with 
many  other  American  surgeons,  has  attained,  we  also 
may  be  proud  that,  in  the  mother  tongue,  a  classical 
work  has  been  produced  which  need  not  fear  compa- 
rison with  the  standard  treatises  of  any  other  nation. 
—Edinhttrgh  Med.  Joxirnal,  Dec.  1866. 

The  credit  of  giving  to  the  profession  the  only  com 
plete  practical  treatise  on  fractures  and  dislocations 
in  our  language  during  the  present  century,  belongs 
to  the  author  of  the  work  before  us,  a  distinguished 


American  professor  of  surgery ;  and  his  book  adds 
one  more  to  the  listof  excellent  practical  works  which 
have  emanated  from  his  country,  notices  of  which 
have  appeared  from  time  to  time  in  our  columns  du- 
ring the  last  few  months.  — iondore  Lancet,  Dec.  15, 
1866. 

These  additions  make  the  work  much  more  valua- 
ble, and  it  must  be  accepted  as  the  most  complete 
monograph  on  the  subject,  certainly  in  our  own,  if 
not  even  in  any  other  language.— .<l?»«nc«n.  Journal 
Med.  Sciences,  Jan.  1867. 

This  is  the  most  complete  treatise  on  the  subject  in 
English  language. —iJanfcin£r'*.46sfra<;<,  Jan.  1867. 

A  mirror  of  all  that  is  valuable  in  modern  surgery. 
Richmond  Med.  Journal,  Nov.  1866. 


BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 
1  vol.  Svo.,  3.'J0  pp.;  cloth,  $1  25. 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  of  Spr«ert.  In  one  very  large  octavo 
volume,  extra  cloth,  of  750  pages.    $2  00. 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUB- 
GEKT.  Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp.,  leather,  raised  bands.  $6  50. 

MACKENZIE  ON  DISEASES  AND  INJURIES  OP 
THE  EYE.     1  vol.  8vo.,  1027  pp.,  extra  cloth,     -te. 


ASHTON  [T.  J.). 
ON  THE   DISEASES,  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages.     $3  25.     {Jtist  Issued.) 


We  can  recommend  this  volume  of  Mr  Asbton's  in 
thestrongpst  terms,  as  containing  all  the  latest  details 
of  the  pathology  and  treatment  of  diseases  connected 
with  the  rectum. — Canada  Med.  Journ.,  March,  18fJ6. 

One  of  the  most  valuable  special  treatise-  that  the 
physician  and  surgeon  can  have  in  his  library. — 
Chicago  Medical  Examintr,  Jan.  18«6. 


[  The  short  period  which  has  elapsed  since  the  ap- 
pearance of  the  former  American  reprint,  and  the 
numerous  editions  published  in  England,  are  the  best 
arguments  we  can  offer  of  the  merit.-',  and  of  the  use- 
lessness  of  any  commendation  on  our  part  of  a  book 
already  so  favorably  known  to  our  readers, — Bo.^bn 
Med.  etnd  Stcrg.  Journal,  Jan.  25,  1866. 


li  OR  LAND  [W.  W.),  M.D. 

DISEASES  OF  THE  URINARY  ORGANS;  a  Compendium  of  their 

Diagnosis,  Pathology,  and  Treatment.     With  illustrations      In  one  large  and  handsome 
octavo  volume  of  about  600  pages,  extra  cloth,     %'i  50. 


Henry  C.  Lea's  Publications — (Surgery). 


29 


ELLS  {J.  SOELBERG), 

Pro/eSMor  of  Ophthalmology  in  King's  College  Uospitnl.  &c. 


w 

A   TREATISE   ON    DISEASES   OP   THE   EYE.     First  American 

Edition,  with  additions;  illustrated  with  216  engravings  on  wood,  and  six  colored  plates. 
Together  with  selections  from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  and 
very  handsome  octavo  volume  of  about  750  pages :  extra  cioth,  $5  00  j  leather,  $6  00. 
(Just  Issued.) 

A  work  has  long  been  wanting  which  should  represent  adequately  and  completely  the  present 
aspect  of  British  Ophthalmology,  and  this  want  it  has  been  the  aim  of  Mr.  Wells  to  supply.  The 
favorable  reception  of  his  volume  by  the  medical  press  is  a  guarantee  that  he  has  succeeded  in 
his  undertaking,  and  in  reproducing  the  work  in  this  country  every  effort  has  been  made  to 
render  it  in  every  way  suited  to  the  wants  of  the  American  practitioner.  Such  additions  aa 
seemed  desirable  have  been  introduced  by  the  editor,  Dr.  I.  Minis  Hays,  and  the  number  of 
illustrations  has  been  more  than  doubled.  The  importance  of  test-types  as  an  aid  to  diagno.<=is 
is  so  universally  acknowledged  at  the  present  day  that  it  seemed  essential  to  the  completeness  of 
the  work  that  they  should  be  added,  and  as  the  author  recommends  the  use  of  those  both  of  Jaeger 
and  of  Snellen  for  different  purposes,  selections  have  been  made  from  each,  so  that  the  practitioner 
may  have  at  command  all  the  assistance  necessary.  The  work  is  thus  presented  as  in  every  way 
fitted  to  merit  the  confidence  of  the  American  profession. 

His  chapters  are  eminently  readable.  His  style  is  i  represented  in  the  preface,  in  prodncing  "  an  English 
clear  and  flowing.  He  can  be  short  without  over-con-  treatise  on  the  diseases  of  the  eye,  which  should 
deuslng,  and  accurate  without  hair  splitting.  These  embrace  the  modern  doctrines  and  practice  of  the 
merits  appear  in  a  remarkable  degree  when  he  comes  British  and  Foreign  Schools  of  Ophthalmology."  The 
to  treat  of  the  more  abstruse  departments  of  his  sub-  new  school  of  Ophthalmology  may  also  be  congratu- 
ject,andcontra8tfavorably  with  the  labored  obscurity  lated  in  having  found  an  exponent  who  is  neither  a 
which  mars  the  writings  of  some  greater  authorities  bigoted  parti.san  of  everything  new,  nor  a  scatter  at 
in  the  same  line.  We  congratulate  Mr.  Wells  npon  everything  old. — Glasgow  if«3.  Journal,  May,  1669. 
the  success  with  which  he  has  fulfilled  his  ideal,  as  I 


rPOYNBEE  [JOSEPH),  F.R.S., 

•*•  Aural  Surgeon  to  and  Lecturer  on  Surgery 

THE  DISEASES  OF  THE  EAR 

ment.     With  one  hundred  engravings  on 
handsomely  printed  octavo  volume  of  440 

The  appearance  of  a  volume  of  Mr.  Toynbee's,  there- 
fore, in  which  the  subject  of  aural  disease  is  treated 
in  the  most  scientific  manner,  and  our  knowledge  in 
respect  to  it  placed  fully  on  a  par  with  that  which 
we  possess  respecting  most  other  organs  of  the  body, 
ie  a  matter  for  sincere  congratulation.  We  may  rea- 
sonably hope  that  henceforth  the  subject  of  this  trea- 
tise will  cease  to  be  among  the  opprobria  of  medical 
science. — London  Medical  Seview. 


at  St.  Mary's  Hospital. 

:  their  Nature,  Diagnosis,  and  Treat- 
wood.  Second  American  edition.  In  one  very 
pages ;  extra  cloth,  $4. 

The  work,  as  was  stated  at  the  outset  o'our  notice, 
is  a  model  of  its  kind,  and  every  page  and  paragraph 
of  it  are  worthy  of  the  most  thorough  study.  Con- 
sidered all  in  all — as  an  original  work,  well  written, 
philosophically  elaborated,  and  happily  illustrated 
with  cases  and  drawings — it  is  by  far  the  ablest  mo- 
nograph that  has  ever  appeared  on  the  anatomy  and 
diseases  of  the  ear,  and  one  of  the  most  valuable  con- 
tributions to  the  art  and  science  of  surgery  in  the 
nineteenth  century. — N.  Am.  Med.-Ohirurg.  JRevieto. 


^  A  URENCE  [JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Seview,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC   SURGERY,  for  the  use  of 

Practitioners.     Second  Edition,  revised  and  enlarged.     With  numerous  illustrations.     In 
one  very  handsome  octavo  volume,  extra  cloth,  $3  00.     (No4o  Ready.) 


No  book  on  ophthalmic  surgery  was  more  needed. 
Designed,  as  it  is,  for  the  wants  of  the  busy  practi- 
tioner, it  is  the  neplus  ultra  of  perfection.  It  epito- 
mizes all  the  diseases  incidental  to  the  eye  in  a  clear 
a4id  masterly  manner,  not  only  enabling  the  practi- 
tioner readily  to  diagnose  each  variety  of  disease,  but 
affording  him  the  more  imporiant  assistance  of  proper 
h'eatment.  Altogether  this  Is  a  work  which  ought 
certainly  to  be  in  the  hands  of  every  general  practi- 
tioner.— Ihiblin  Med.  Pre-i^  and  Circular,  Sept.  12,  '66 

We  cordially  recommend  this  book  to  the  notice  of 
our  readers,  as  containing  an  excellent  outline  of 
modern  ophthalmic  surgery. — British  Med.  Journal, 
October  13,  1866. 


Not  only,  as  Its  modest  title  suggests,  a  "Handy- 
Book"  of  Ophthalmic  Surgery,  but  an  excellent  and 
well-digested  risumi  of  all  that  is  of  practical  value 
in  the  specialty.— iView  York  Medical  Journal,  No- 
vember, 1S66. 

Thi.s  object  the  authors  have  accomplished  in  a 
highly  satisfactory  manner,  and  we  know  no  work 
we  can  more  highly  recommend  to  the  "busy  practi- 
tioner" who  wishes  to  make  himself  acquainted  with 
the  recent  improvements  in  ophtljalmic  science.  Such 
a  work  as  this  was  much  wanted  at  this  time,  and 
this  want  Messrs.  Laurence  and  Moon  have  now  well 
I  supplied. — Am.  Journal  Med.  Sciences,  Jan.  1667. 


TAWSON  [GEORGE],  F.  R.  C.  S.,  Engl, 

•^  Assistarit  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moor  fields,  Ac. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 
diate and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand- 
some octavo  volume,  extra  cloth,  $3  50 

This  work  will  be  found  eminently  fitted  for  the  general  practitioner.  In  cases  of  functional 
or  structural  diseases  of  the  eye,  the  physician  who  has  not  made  ophthalmic  surgery  a  special 
study  can,  in  most  instances,  refer  a  patient  to  some  competent  practitioner.  Cases  of  injury, 
however,  supervene  suddenly  and  usually  require  prompt  assistance,  and  a  work  devoted  espe- 
cially to  them  cannot  but  prove  essentially  useful  to  those  who  may  at  any  moment  be  called  upon- 
to  treat  such  accidents.  The  present  volume,  as  the  work  of  a  gentleman  of  large  experience, 
may  be  considered  as  eminently  worthy  of  confidence  for  reference  in  all  such  emergencies. 

It  is  an  admirable  practical  book  in  the  highest  and  best  sense  of  the  phrase. — London  Medical  Times 
mnd  Gaiette,  May  18,  1S67. 


30 


Henry  C.  Lea's  Publications — (Surgery). 


IJl^LES  [PHILIP  S.),  M.  B.,  Surgeon  U.S.N. 


MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical 

Apparatus,   Appliances,  and  Elementary  Operations:    embracing  Minor  Surgery,  Band. 

aging.  Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.     With  six  hundred 

and  forty-two  illustrations  on  wood.     In  one  large  and  handsome  octavo  volume  of  about 

700  pages:  extra  cloth,  $5  75;  leather,  $6  75.     {Just  Issi/efl.) 
A  Naval  Medical  Board  directed  to  examine  and  report  upon  the  merits  of  this  volume,  officially 
states  that  "  it  should  in  our  opinion  become  a  standard  work  in  the  hands  of  every  naval  sur- 
geon ;"  and  its  adoption  for  use  in  both  the  Army  and  Navy  of  the  United  States  is  sufficient 
guarantee  of  its  adaptation  to  the  needs  of  every-day  practice. 

The  title  of  this  book  will  give  a  reasonably  gooU 
Idea  of  its  scope,  bat  its  merits  can  only  be  appreci- 
ated by  a  careful  perusal  of  its  text.  No  one  who  ua- 
dertakes  such  a  task  will  have  any  reason  to  com- 
plain that  the  author  has  not  performed  bis  duty,  and 
has  not  taken  every  pains  to  present  every  subject  in 
a  clear,  comraon-seuse,  and  practical  light.  It  is  a 
unique  specimen  of  literature  in  its  way,  in  that, 
treating  upon  such  a  variety  of  subjects,  it  is  as  a 
whole  so  completely  up  to  tiie  wants  of  the  student 
and  tM  general  practitioner.  We  have  never  t-een 
any  work  of  its  kind  that  can  compete  with  it  in  real 
utility  and  extensive  adaptability.  Dr.  Wales  per- 
fectly understands  what  may  naturally  be  required 
of  him  in  the  premises,  and  in  the  work  before  us  has 
bridged  over  a  very  wide  gap  which  has  always  here- 
tofore existed  between  the  first  rudiments  of  surgery 
and  practical  surgery  proper.  He  has  emphatically 
given  us  a  comprehensive  work  for  the  beginner  ;  and 
when  we  say  of  his  labors,  that  in  their  particular 
sphere  they  leave  nothing  to  be  desired,  we  assert  a 
great  deal  to  recommend  the  book  to  the  attention  of 
those  specially  concerned.  In  conclusion,  we  would 
state,  at  the  risk  of  reiteration,  that  this  is  the  most 
compi'ehensive  book  on  the  subject  that  we  have  seen  ; 
is  the  best  that  can  be  placed  in  the  hands  of  the  stu- 


deut  in  need  of  a  first  book  on  surgery,  and  the  most 
useful  that  can  be  named  for  such  general  practition- 
ers who,  without  any  special  pretensions  to  surgery, 
are  occasionally  liable  to  treat  surgical  cases. — N.  Y. 
Med.  Record,  March  2,  1868. 

It  is  certainly  the  most  complete  and  thorough  work 
of  its  kind  in  the  English  language.  Students  and 
young  practitioners  of  surgery  willfind  it  invaluable. 
It  will  prove  especially  useful  to  inexperienced  conn- 
try  practitioners,  who  are  continually  required  to 
take  charge  of  surgical  cases,  under  circumstances 
precluding  thera  from  the  aid  of  experienced  surgeons. 
— Pacific  Med.  and  Surg.  Journal,  Feb.  1868. 

The  title  of -the  above  work  is  sufficiently  indica- 
tive of  its  contents.  We  have  not  seen  for  a  long 
lime  (in  the  English  language)  a  treatise  equal  to  thia 
in  extent,  nor  one  which  is  better  adapted  to  tJie 
wants  of  the  general  student  and  practitioner.  It  is 
not  to  the  surgeon  alone  that  this  book  belongs ;  tli« 
physician  has  frequent  opportunities  to  fill  an  emer- 
gency by  such  knowledge  as  is  here  given.  Every 
practitioner  should  make  purchase  of  such  a  book — 
it  will  last  him  his  lifetime. — Ht.  Louis  Med.  Re- 
porter, Feb.  1S88. 


T>IGELO  W  [HENRY  J.),  M.  D., 

-'-'  Professor  of  Surgery  in  the  Massachusetts  Med.  College. 

ON   THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.     With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.     With 
numerous  original  illustrations.     In  one  very  handsome  octavo  volume.     Cloth.     $2  50. 
{Jtist  Issued.) 
We  cannot  too  highly  praise  this  book  as  the  work    graph  is  largely  illustrated  with  exquisitely  executed 
of  an  accomplished  and  scientiflc  surgeon.     We  do     woodcuts,  after  photogr«phs,  which  help  to  elucidalo 
'  not  hesitate  to  siiy  that  he  has  done  much  to  clear  up     the  admirable  subject-matter  of  the  text.     We  cor- 
the  obscurities  connected  with  the  mechanism  of  dis-     dially  commend  the  "  Hip,"  by  Dr.  Bigelow,  to  the 
location  of  the  hip-joint,  and  he  has  laid  down  most     attention  of  surgeons. — Dtvblin  Quarter ly  Journal  ()f 
valuable  practical  rules  for  the  easy  and  most  sue-     Medical  Science,  Feb.  1870. 
cessful  management  of  these  injurie'si-   The  mono- 


mnoMPsoN  [SIR  henr  y), 

J-  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital. 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.   With 

illustrations  on  wood.     In  one  neat  octavo  volume,  extra  cloth.     $2  25.     (Just  Issued.) 


These  lectures  stand  the  severe  test.  They  are  in- 
structive without  being  tedious,  and  simple  without 
being  diffuse;  and  they  iuclude  many  of  those  prac- 
tical hints  so  useful  for  the  student,  and  even  more 
valuable  to  the  young  practitioner. — Edinburgh  Med. 
Journal,  April,  1869. 

Very  few  words  of  ours  are  necessary  to  recommend 
these  lectures  to  the  profession.    There  is  no  subject 


on  which  Sir  Henry  Thompson  speaks  with  more  au- 
thority than  that  in  which  he  has  specially  gathered 
his  laurels;  in  addition  to  this,  the  conversational 
style  of  instruction,  wliich  is  retained  in  these  printed 
lectures,  gives  them  an  attractiveness  which  a  sys- 
tematic treatise  can  never  possess. — Loiidoi^  Medieal 
Times  and  Gazette,  April  24,  1S6».  , 


■DT  THE  SAME  AUTHOR. 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OP 

THE  URETHRA  AND  URINARY  FISTULA.  Wjth  plates  and  wood-cuts.  From  the 
third  and. revised  English  edition.  In  one  very  handaome  octavo  volume,  extra  cloth,  $3  60. 
{Just  Issued.) 

Thi.s  classical  work  has  so  long  been  recognized  as  a  standard  authority  on  its  perplexing  sub- 
jects that  it  should  be  rendered  accessible  to  the  American  profession.  Having  enjoyed  the 
advantage  of  a  revision  at  the  hands  of  the  author  within  a  few  months,  it  will  be  found  to  present 
his  latest  views  and  to  be  on  a  level  with  the  most  recent  advances  of  surgical  science- 

With  a  work  accepted  as  the  authority  upon  the  I  ably  known  by  the  profession  as  this  before  us,  must 
tubjects  of  whidi  it  treats,  an  extended  notice  Would  |  create  a  demand  for  it  from  those  who  would  keep 
be  a  work  of  supererogatiou.  The  simjile  auuouuce-  I  themselves  well  up  in  this  department  of  surgery.— 
ment  of  another  edition  of  a  work  so  well  and  favor-  |  St.  Louis  Med.  Archives,  Feb.  1870. 


Henry  C.  Lea's  Publications — {Medical  Juriiiprudenre,  i%c.).     31 
fTAYLOR  {ALFRED  S.),  M.D., 

■*-  Lecturer  on  Mt-d.  Jurisp.  find  ChmtUntry  in  Guy's  ffnspitnl. 

MEDICAL   JURISPRUDENCE.     Sixth   American,  from   the  eighth 

and  revised  London  edition.  With  Notes  and  References  to  American  Decisions,  bj-'cLE- 
ME.VT  B.  Penrose,  of  the  Philadelphia  Bar.  In  one  large  octavo  volume  of  776  pages, 
extra  cloth,  $4  50  ;  leather,  $5  50.      (J?t.'!t  Issued.) 

Considerable  additions  have  been  made  by  the  editor  to  this  edition,  comprising  some  important 
sections  from  the  author's  larger  work,  "  The  Principles  and  Practice  of  Medical  Jurisprudence," 
a;s  well  as  references  to  American  law  and  practice.  The  notes  of  the  former  editor.  Dr.  Harts- 
home,  have  likewise  been  retained,  and  the  whole  is  presented  as  fully  worthy  to  maintain  the 
di.'tinguished  position  which  the  work  has  acquired  as  a  leading  text-book  and  authority  on  the 
subject. 

A  Lew  edition  of  a  work  acknowledged  as  a  stand-  I  nected  with  forensic  medicine,  and  every  successive 
ard  authority  everywhere  within  the  range  of  the  1  edition  of  his  valuable  work  gives  fresh  assurance  to 
English  language.  Considering  the  new  matter  intro-  j  his  many  admirers  thut  he  will  continue  to  maintain 
duced,  on  tricliiniasis  and  other  subjects,  and  the  |  his  well-earned  position.  No  one  should,  in  fact,  be 
plates  representing  the  crystalsof  poisons,  etc.,  it  may  i  without  a  text-book  on  the  subject,  as  he  does  not 
fairly  be  regarded  as  the  most  compact,  comprehen-  '  know  but  that  his  next  case  may  create  for  him  an 
give,  and  practical  work  on  medical  jurisprudence  '  emergency  for  its  use.  To  those  who  are  not  the  for- 
which  has  issued  from  the  press,  and  the  one  best  !  Innate  possessors  of  a  reliable,  readable,  interesting, 
fitted  for  students.— Poci/Jc  Med.  and  Surg.  Journal,  I  and  thoroughly  practical  work  upon  the  subject,  we 


would  earnestly  recommend  this,  as  forming  the  best 
groundwork  for  all  their  future  studies  of.  the  more 
elaborate  treatises. — yeio  York  Medical  Record,  Feb. 
1.5,  lSt)7. 

The  present  edition  of  this  valuable  manual  is 


Feb.  1867. 

The  sixth  edition  of  this  popular  work  comes  to  us 
in  charge  of  a  new  editor,  Mr.  Penrose,  of  the  Phila- 
delphia bar,  who  has  done  much  to  render  it  useful, 
not  only  to  the  medical  practitioners  of  this  country, 

but  to  those  of  his  own  profession.  Wisely  retaining  great  improvement  on  those  which  have  preceded  it. 
the  references  of  the  former  American  editor,  Dr.  i  It  makes  thus  by  far  the  best  guide-book  in  this  de- 
Hartshorne,  he  has  added  many  valuable  notes  of  his  i  partment  of  medicine  for  students  and  the  gen'?ral 
own.  The  reputation  of  Dr.  Taylor's  work  is  so  well  '  practitioner  in  our  language. — Boston  Med.  and  Surg . 
established,  that  il  needs  no  recommendation.  He  is  i  Journal,  Dec.  27,  IStiS. 
now  the  higliest  living  authority  on  all  matters  con-  I  •  ' 


^yiNSLOW  [FORBES],  M.D.,  D.C.L.,  ^c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

Of  the  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo,  volume  of  nearly  600  pages,  extra  cloth.     $4  25.     (Just  Issued.) 

Of  the  merits  of  Dr.  Winslow's  treatise  the  profes-  thereby  undertaken  responsibilities  in  which  the 
Bion  has  sufficiently  judged.  It  has  taken  its  place  in  welfare  and  happiness  of  individuals  and  families 
the  front  rank  of  the  works  upon  the  special  depart-  ;  are  largely  involved.  We  shall  therefore  close  this 
ment  of  practical  medicine  tp  which  it  pertains. —  i  brief  and  necessarily  very  imperfect  notice  of  Dr. 
Cincinnati  Journal  of  Medicine,  Ma,Tch,\S(i6.  |  Winslow's  great  and  classical  work  by  expressing 

It  is  an  interesting  volume  that  will  amply  repay  '  °^^  convictiofl  that  it  is  long  since  so  important  and 
for  a  careful  perusal  by  all  intelligent  readers.— 1  ^eaalifnlly  written  a  volnrae  has  issued  from  the 
Chicago  Med  Examiner  Feb.  1866.  British  medical  press.— InMm  Medical  Prtxs. 

A  work  which,  like  the  present,  will  largely  aid  '  It  is  the  most  interesting  as  well  as  valuable  book 
the  practitioner  in  recognizing  and  arresting  the  first  1  ^^^^  ^e  have  seen  for  a  long  time.  It  is  truly  fasci- 
insidlous  advances  of  cerebral  and  mental  disease,  is  |  uating.— ^wi.  Jour.  Med.  {sciences. 
one  of  immense  practical  value,  and  demands  earnest  j  Dr.  Winslow's  work  will  undoubtedly  occupy  an 
attention  and  diligent  study  on  the  part  of  all  who  '  unique  position  in  the  medico-p.sychological  litera- 
have   embraced   the   medical   profession,   and   have  j  ture  of  this  country. — London  Med.  Review. 

T  EA  {HENRY  C). 

SUPERSTITION    AND    FORCE:    ESSAYS    ON    Tfe[E  WAGER  OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Second  Edition, 

Enlarged.     la  fine  handsome  volume  royal  12mo.  of  nearly  500  pages;  extra  cloth,  §2  75. 

{Just  Issued.) 

The  copious  collection  of  facts  by  which  Mr.  Lea  has  j  a  humor  so  fine  and  good,  that  he  makes  us  regret  it 

Illustrated  hissubject  shows  in  the  fullest  manner  the  j  was  not  within  his  intent,  as  it  was  certainly  within 

constant  conflict  and  varying  success,  the  advances    his  power,  to  render  the  whole  of  his  thorough  woik 


and  defeats,  by  which  the  progress  of  humane  legisla- 
tiou  has  been  and  is  still  marked.  This  work  fills  up 
with  the  fullest  exemplification  and  detail  the  wise 
remarks  which  we  have  <4uoted  above.  As  a  book  of 
ready  reference  on  the  subject  it  is  of  the  highest 
value. —  Wt.itrninister  Review,  Oct.  1867. 

When — half  in  spite  of  himself,  as  it  appears — he 
sketches  a  scene  or  character  in  the  history  of  legalized 
error  and  cruelty,  he  betrays  so  artistic  a  feeling,  and 


more  popular  in  manner. — Atlantic  Monthly,  Feb.  '67. 
This  is  a  book  of  extraordinary  research.  Mr.  Lea 
has  entered  into  his  subject  con  amore ;  and  a  more 
striking  record  of  the  cruel  superstitious  of  our  un- 
happy Middle  Ages  could  not  possibly  have  been  com- 
piled. ...  As  a  work  of  curious  inquiry  on  certain 
outlying  points  of  obsolete  law,  "Superstition  and 
Force'  is  one  of  the  most  remarkable  books  we  have 
met  with. — London  Atluai(eu,m,  Kov.  3, 1866. 


B 


Y  THE  SAME  AUTHOR.    (JuH  Issued.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large  royal 
12mo.  volume  of  516  pp.  extra  cloth.     $2  75. 

is  shown  in  weaving  in  anecdote  and  picturesque 
stories,  without  impairing  the  flow  of  the  relation  or 
the  proper  dignity  of  the  composition. — Hartford 
Oiurant,  Jan.  22, '1870. 

We  recommend  the  book  as  a  highly  instructive 
discussion  of  matters  which  are  always  of  interest  to 
scholars,  and  which  are  just  aowclothed  with  a  spe- 
cial importance.— A".  Y.  Nation,  Feb.  3,  1870. 


Altogether,  the  book  is  a  useful  addition  to  the  po- 
pular literature  of  a  most  important  and  too  little 
known  department  of  mediieval  history. — London 
Saturday  Review,  Feb.  26,  1870. 

They  are  careful  studies  by  a  thorough  scholar  in 
the  most  interesting  of  all  historical  fields,  made 
without  passion  or  prejudice,  and  recorded  with  hon- 
esty. The  whole  volunie  is  of  the  deepest  interest ; 
the  style  is  masculine  and  animated,  and  great  skill 


32 


Henry  C.  Lea's  Publications. 


INDEX    TO    CATALOGUE. 


Allen's  Dissector  and  Practical  Anatomist 
Amei'ican  Journal  of  the  Medical  Sciences 
Abstract,  Half-Yearly,  of  the  Med   Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  Ihe  Rectum  and  Anus  . 
Attfield's  Chemistry 
Ashwell  on  Diseases  of  Females  . 
Basham  on  Renal  Diseases     . 
Brlnton  on  the  Stomach 
Bigelow  on  the  Hip 
Barclay  s  Medical  Diagnosis  . 
Barlow's  Practice  of  Medicine 
Bowman's  (John  E.)  Practical  Chemistry 
Bowman's  (John  E.)  Medical  Chemistry 
Brande  &  Taylor's  Chemistry 
Brodie's  Clinical  Lectures  on  Surgery  . 
Brown  on  the  Surgical  Diseases  of  Women 
Buckler  on  Bronchitis     .... 
Bucknill  and  Tuke  on  Insanity 
Bumstead  on  Venereal    .... 
Bumstead  and  CuUerier's  Atlas  of  Venereal 
Carpenter's  Human  Physiology    . 
Carpenter's  Comparative  Physiology   . 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson's  Synopsis  of  Materia  Medica    . 
Chambers  on  tne  Indigestions 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery  . 
Churchill  on  Diseases  of  Females 
Churchill  on  Puerperal  Fever 

Clymer  on  Fevers 

Coudie  on  Diseases  of  Children     . 
Cooper's  (B.  B  )  Lectures  on  Surgery    . 
CuUerier's  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine  . 
Dalton's  Human  Physiology .        .        . 
De  Jongh  on  Cod-Liver  Oil     . 
Dewees's  System  of  Midwifery 
Dewees  on  Diseases  of  Females     . 
Dewees  on  Diseases  of  Children    .        . 
Dickson's  Practice  of  Medicine      .        . 
Druitt's  Modern  Surgery        .        ,        . 
Dunglison's  Medical  Dictionary    . 
Dunglison's  Human  Physiology    . 
Dunglison  on  New  Remedies 
Ellis's  Medical  Formulary,  by  Smith  . 
Erichsen's  System  of  Surgery 
Erichsen  on  Nervous  Injuries 
Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart 

Flint's  Practice  of  Medicine  . 
Fownes's  Elementary  Chemistry  . 
Fuller  on  the  Lungs,  &c.        .        .        . 

Gibson's  Surgery 

Gluge's  Pathological  Histology,  by  Leidjr 
Graham's  Elements  of  Chemistry  .        . 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross's  Principles  and  Practice  of  Surgery 
Gross's  Pathological  Anatomy 
Hartshorne's  Essentials  of  Medicine    . 
Hartshorne's  Conspectus  of  the  Jledical  Sciences 
Hartshorne's  Anatomy  and  Physiology 
Habershon  on  Alimentary  Canal  . 
Hamilton  on  Dislocations  and  Fractares 
Harrison  on  the  Nervous  Syst<^m  . 
Heath's  Practical  Anatomy    . 
Hoblyn's  Medical  Dictionary 

Hodge  on  Women 

Hodge's  Obstetrics 

Hodge's  Practical  Dissections 
Holland's  Medical  Notes  and  Reflections 
Horner's  Aaatotny  and  Histology 
Hudson  on  Fevers,  .... 

Hill  on  Venereal  Diseases 
Hillier's  Handbook  of  Skin  Diseases 
Jones  and  Sieveking's  Pathological  Anatomy 
Jones  (C.  Handfiold)  on  Nervous  Disorders 

Kirkes'  Physiology 

Knapp's  Cliemioal  Technology     . 
Lea's  Superstition  and  Force 


dged 


Lea's  Studies  in  Church  History    . 
Lallemand  and  Wilson  on  Spermatorrhoea 
La  Roche  on  Yellow  Fever     . 
La  Roche  on  Pneumonia,  &c. 
Laurence  and  Moon's  Ophthalmic  Surgery 
Lawson  on  the  Eye  .... 

Laycock  on  Medical  Observation  . 
Lehmann's  Physiological  Chemistry,  2  vols, 
Lehmann's  Chemical  Physiology  . 
Ludlow's  Manual  of  Examinations 

Lyons  on  Fever 

Maclise's  Surgical  Anatomy  . 

Malgaigne's  Operative  Surgery,  by  Brittan 

Marshall's  Physiology    . 

Mayiie's  Dispensatory  and  Formulary 

Mackenzie  on  Diseases  of  the  Eye 

Medical  News  and  Library    . 

Meigs's  Obstetrics,  the-Science  and  the  Art 

Meigs's  Lectures  on  Diseases  of  Women 

Meigs  on  Puerperal  Fever 

Miller's  System  of  Obstetrics         . 

Miller's  Practice  of  Surgery  .        . 

Miller's  Principles  of  Surgery       . 

Montgomery  on  Pregnancy    . 

Morland  on  Urinary  Organs  . 

Morland  on  Ureemia         .... 

Neil  I  and  Smith's  Compendium  of  Med.  Science 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Neligan  on  Diseases  of  the  Skin    . 

Odling's  Practical  Chemistry 

Pavy  on  Digestion  .... 

Prize  Essays  on  Consumption 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery     .        .       ". 

Pereira's  Mat.  Medica  and  Therapeutics,  abr 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Rauking's  Abstract  .... 

Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  .        . 

Rigby  on  Female  Diseases      .        .  '      . 

Rigby's  Midwifery  ..... 

Rokiiansky's  Pathological  Anatomy     . 

Royle's  Materia  Medica  and  Therapeutics 

Salter  on  Asthma 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Simon's  General  Pathology    .        . 

Simpson  on  Females        .... 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  of  Children 

Solly  on  Anatomy  and  Diseases  of  the  Brain 

Still6's  Therapeutics        . 

Tanner's  Manual  of  Clinical  Medicine 

Tanner  on  Pregnancy 

Taylor's  Medical  Jurisprudence     . 

Thomas  on  Diseases  of  Females    . 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture    . 

Todd  and  Bowman's  Physiological  Anatomy 

Todd  on  Acute  Diseases  .... 

Toynbee  on  the  Ear         .... 

Wales  on  Surgical  Operations 

Walslie  on  the  Heart      .        .        .        . 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye 

West  on  Diseases  of  Females 
West  on  Diseases  of  Children 
West  on  Ulceration  of  Os  Uteri 
What  to  Observe  in  Medical  Cases 
Williams's  Principles  of  Medicine 
Wilson's  Human  Anatomy    . 

Wilson's  Dissector 

Wilson  on  Diseases  of  the  Skin     . 
Wilson's  Plates  on  Diseases  of  the  Skin 
Wilson's  Handbook  of  Cutaneous  Medicine 
Wilson  on  Sperniatorrbcea 
Wiuslow  on  Brain  and  Miud 


PAOB 

31 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


076 


^PR    5R£C'D 


Form  L9-Series  4939 


r.C' 


